Dieter Fassbender

Nonsurgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy Outcome in the First Series of Patients

BACKGROUND Some patients with hypertrophic obstructive cardiomyopathy may gain symptomatic relief from a reduction in the extent of obstruction to left ventricular outflow. We present the outcome of the first series of patients treated with an alternative method of gradient reduction using catheter techniques. METHODS AND RESULTS Eighteen patients were treated with selective intracoronary alcohol injection to induce localized septal infarction. Patients underwent echocardiographic measurement of left ventricular dimensions and Doppler echocardiographic evaluation of left ventricular outflow tract gradients before the procedure, on the first postoperative day, and at a median follow-up of 3 months after the procedure. In addition, patients underwent exercise testing and symptom evaluation before and 3 months after nonsurgical septal reduction. There was a significant reduction in left ventricular outflow tract obstruction after the procedure (preprocedure, 67 mm Hg [95% CI, 48 to 87 mm Hg]; postprocedure, 25 mm Hg [95% CI, 16 to 34 mm Hg]; P=.0006), which persisted at 3-month follow-up (22 mm Hg [95% CI, 12 to 32 mm Hg]; P=.001). This was associated with a significant improvement in symptoms. There was a small but not significant increase in exercise capacity (n=10; preprocedure, 418 seconds [95% CI, 273 to 563 seconds]; postprocedure, 452 seconds [95% CI, 283 to 621 seconds). Left ventricular dimensions were not significantly altered by nonsurgical septal reduction. CONCLUSIONS Nonsurgical septal reduction significantly reduces left ventricular outflow tract obstruction and improves symptoms in some patients with hypertrophic obstructive cardiomyopathy. The technique may provide an alternative to surgical myomectomy in selected patients.

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute results and 3-month follow-up in 25 patients.

OBJECTIVES We report the acute results and midterm clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND In the treatment of HOCM, surgical myectomy and DDD pacemaker therapy are considered the standard procedural extensions to drug therapy with negatively inotropic drugs. As an alternative nonsurgical procedure for reducing the left ventricular outflow tract (LVOT) gradient, PTSMA by alcohol-induced septal branch occlusion was introduced. However, clinical follow-up has not been sufficiently described. METHODS In 25 patients (13 women, 12 men; mean [+/- SD] age 54.7 +/- 15.0 years) who were symptomatic despite sufficient drug therapy, 1.4 +/- 0.6 septal branches were occluded with an injection of 4.1 +/- 2.6 ml of alcohol (96%) to ablate the hypertrophied interventricular septum. After 3-months, follow-up results of LVOT gradients and clinical course were determined. RESULTS The invasively determined LVOT gradients could be reduced in 22 patients (88%), with a mean reduction from 61.8 +/- 29.8 mm Hg (range 4 to 152) to 19.4 +/- 20.8 mm Hg (range 0 to 74) at rest (p < 0.0001) and from 141.4 +/- 45.3 mm Hg (range 76 to 240) to 61.1 +/- 40.1 mm Hg (range 0 to 135) after extrasystole. All patients had angina pectoris for 24 h. The maximal creatine kinase increase was 780 +/- 436 U/liter (range 305 to 1,810) after 11.1 +/- 6.0 h (range 4 to 24). Thirteen patients (52%) developed a trifascicular block for 5 min to 8 days requiring temporary (n = 8 [32%]) or permanent (DDD) pacemaker implantation (n = 5 [20%]). An 86-year old woman died 8 days after successful intervention of uncontrollable ventricular fibrillation in conjunction with beta-sympathomimetics in chronically obstructive pulmonary disease. The remaining patients were discharged after 11.3 +/- 5.4 days (range 5 to 24), after an uncomplicated hospital course. Clinical and echocardiographic follow-up was achieved in all 24 surviving patients after 3 months. No cardiac complications occurred. Twenty-one patients (88%) showed clinical improvement, with a New York Heart Association functional class of 1.4 +/- 1.1. A further reduction in LVOT gradient was shown in 14 patients (58%). CONCLUSIONS PTSMA of HOCM is a promising nonsurgical technique for septal myocardial reduction, with a consecutive reduction in LVOT gradient. Possible complications are trifascicular blocks, requiring permanent pacemaker implantation, and tachycardiac rhythm disturbances. Clinical long-term observations of larger patient series and a comparison with conventional forms of therapy are necessary to determine the conclusive therapeutic significance.

Transcatheter closure of patent foramen ovale in patients with cerebral ischemia

OBJECTIVES The present study was conducted to determine the safety of the transcatheter closure of a patent foramen ovale (PFO) in patients with cryptogenic cerebral ischemia and the midterm follow-up of recurrent thromboembolic events after interventional PFO closure. BACKGROUND Current therapeutic options for stroke prevention in patients with PFO and a history of thromboembolic events include chronic antithrombotics and more invasive treatments such as surgical closure or minor invasive transcatheter permanent closure of the PFO. Promising preliminary and pilot data with the Amplatzer Septal Occluder or the PFO-Star Occluder have been reported. Systematic and long-term data are still missing. METHODS A total of 276 consecutive patients with a PFO and a history of at least one thromboembolic event were recruited in four medical centers and underwent percutaneous PFO closure with the PFO-Star device. Follow-up data were analyzed over an average of 15.1 months, equivalent to 345 patient-years. RESULTS The implantation was successful in all 276 patients. Peri-interventional reversible complications included transient ST-segment elevations (1.8%) and transient ischemic attack (TIA) (0.8%). Two devices have been removed surgically. During follow-up the annual recurrence rate of thromboembolic events was 1.7% for TIA, 0% for stroke and 0% for peripheral emboli. CONCLUSIONS Interventional PFO closure with the PFO-Star device appears to be a reliable and promising technique resulting in a low recurrence rate of thromboembolic events, especially stroke in patients with a history of cryptogenic ischemia presumably due to paradoxical embolization. To our knowledge, this is the largest coherent and prospective study for interventional PFO closure.

One-year follow-up of percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy in 312 patients: predictors of hemodynamic and clinical response

AimThe aim of this study was to analyze hemodynamic and clinical outcome in a cohort of 312 patients who were followed up over a period of 12 months after alcohol septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM).Methods and resultsPTSMA was intended in 337 patients with HOCM (mean age: 54±15 years), with 312 procedures completed by injection of 2.8±1.2 ml of alcohol. In 25 patients (8%) the intervention was aborted, mostly because of contrast echocardiographic findings. In the 312 patients who received alcohol, permanent pacing was necessary in 22 cases (7%); and in-hospital mortality was 1.3% (four patients). During follow-up, contact to six patients (2%) was lost, and three additional patients (1%) died. The 299 patients who either underwent non-invasive reassessment in our institution or transmitted followup data from their local physician formed the study population. Improvement in symptoms was reported by 272 patients (91%). Mean NYHA functional class was reduced from 2.9±0.4 to 1.5±0.7 (p<0.0001) along with a gradient reduction (echo-Doppler) from 59±32 to 8±15 mmHg at rest, and from 120±42 to 28±32 mmHg with provocation (p<0.0001 each). Exercise capacity improved from 94±51 to 119±40 watts (p=0.001), and peak oxygen consumption from 18±4 to 21±6 ml/ kg/min (p=0.01). Younger age and higher outflow gradients at baseline and immediately after intervention were associated with a less favorable hemodynamic outcome. The degree of limitation of exercise capacity at baseline was the only predictor of symptomatic improvement.ConclusionsCatheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. In contrast to a previous study, in this cohort of 312 patients there was no association between post-interventional enzyme release and hemodynamic success. Younger patients with high baseline gradients, however, tended to have a less favorable hemodynamic outcome with higher residual gradients.

Low-dose aspirin versus anticoagulants for prevention of coronary graft occlusion

The prevention of graft occlusion by aspirin (100 mg/day) or heparin followed by phenprocoumon was investigated in a randomized trial in 235 patients after aortocoronary bypass operation. Aspirin treatment started 24 hours before, and heparin 6 hours and phenprocoumon 2 days after surgery. The results of the vein graft angiography and the clinical outcome 3 months postoperatively did not differ: 22% of 218 vein graft distal anastomoses in the aspirin group and 20% of 272 in the anticoagulant group were occluded. At least 1 occluded distal anastomosis was present in 38% of 74 patients in the aspirin-treated group and in 39% of 86 in the anticoagulant group. Worst-case analysis of all randomized patients showed graft occlusions, cardiovascular complications or lost to follow-up in 42% of 122 aspirin-treated patients compared with 41% of 113 patients treated with anticoagulants. For grafts with endarterectomy the occlusion rate was lower in the aspirin (12% of 49) than in the anticoagulant (22% of 41) group (p less than or equal to 0.05). Increased perioperative blood loss in the aspirin group (1,211 +/- 814 ml in the first 48 hours vs 874 +/- 818 ml in the anticoagulant group [p less than or equal to 0.001]) without a higher reoperation rate indicates effective platelet inhibition with low-dose aspirin. Because occlusion rates were equal but high in these patients with advanced stage of coronary artery disease, a combination of low-dose aspirin and anticoagulation should be investigated to reduce graft occlusion rates further.

Vorhersage des Risikos permanenter atrioventrikulärer Überleitungsstörungen nach perkutaner Septumablation bei Patienten mit hypertropher obstruktiver Kardiomyopathie

Background and introduction: Damage to the AV conduction system is a frequent complication of percutaneous septal ablation (PTSMA) that needs early and reliable identification of those patients (pts.) at risk for complete heart block (CHB) and subsequent pacemaker implantation. Methods and results: In the first 39 pts. who underwent PTSMA in 1996, AV conduction recovery needed up to 11 days. One pt. suffered from unexpected CHB after 9 days. Seven pts. who needed a DDD pacemaker (DDD-PM) were compared to those without conduction disturbances. A score was established which identified all DDD-PM candidates retrospectively if they presented with >12 score points. In the following 137 consecutive pts. treated in 1997 and 1998, this score was applied prospectively, and again correctly identified all candidates for a DDD-PM. In addition, a low risk group was identified with <8 score points. From 1999 on, the score was applied in routine clinical decision-making in 120 consecutive pts. with respect to DDD-PM implantation. All low risk pts. (<8 points) remained free from bradycardias, while 2/54 pts. (4%) of the intermediate risk group, and 20/23 pts. (87%) of the high risk group had to undergo DDD-PM implantation. Pts. with a first-degree AV block or those with a right bundle branch block at baseline had no excess risk, while 50% of the pts. with a left bundle branch block (LBBB) needed a DDD-PM. Conclusions: Based on pre-interventional data and careful monitoring of the first 48 hours after PTSMA, identification of pts. at risk for CHB and subsequent DDD-PM implantation seems to be possible. Pts. with a score <8 seem to be at low, those with >12 points at high risk. In the remaining cases watchful waiting with prolonged monitoring may allow AV conduction to recover, thus, reducing the number of unnecessary DDD-PM implantations. In cases with LBBB at baseline, however, implantation of a DDD-PM should be considered first-line therapy. Einleitung: Höhergradige AV-Überleitungsstörungen (AVB) stellen eine häufige Komplikation der perkutanen Septumablation (PTSMA) dar und erfordern eine frühzeitige und verlässliche Identifikation derjenigen Patienten (Pat.), die einen permanenten DDD-Schrittmacher (DDD-SM) benötigen. Methoden und Ergebnisse: Wir beobachteten den Spontanverlauf des AVB bei den ersten 39 im Jahr 1996 mittels PTSMA behandelten Pat., ausgenommen 6 Pat. mit bereits implantiertem DDD-SM bzw. vorbestehenden Erregungsleitungsstörungen, wobei die stabile Erholung einer gestörten Überleitung maximal 11 Tage benötigte. Sieben der verbleibenden 33 Pat. erhielten einen DDD-SM. Der Vergleich dieser Pat. mit denen ohne AVB resultierte in einem Scoresystem, welches mit >12 Punkten retrospektiv alle DDD-SM-Kandidaten identifizierte. Bei den 137 nachfolgenden Pat. der Jahrgänge 1997 und 1998 wurde dieser Score prospektiv angewendet und klassifizierte ebenfalls alle weiteren DDD-SM-Kandidaten korrekt. Darüber hinaus konnte eine Gruppe niedrigen Risikos mit <8 Score-Punkten ermittelt werden. Ab dem Jahr 1999 an erfolgte die Anwendung des Score-Systems bei 120 konsekutiven Pat. in der klinischen Routine. In der Niedrig-Risikogruppe (<8 Punkte) blieben sämtliche Pat. ereignisfrei. Ein DDD-SM war bei 2/52 (4%) der Gruppe mit mittlerem Risiko, und bei 20/23 (87%) der Hochrisikogruppe erforderlich. Ein AV-Block Grad I oder ein Rechtsschenkelblock im Ausgangs-EKG vor PTSMA erhöhte die Wahrscheinlichkeit einer DDD-SM-Implantation nicht, während Pat. mit Linksschenkelblock (LSB) eine Schrittmacher-Quote von 50% aufwiesen. Schlussfolgerung: Basierend auf der Kombination präinterventioneller Daten mit einer sorgfältigen Überwachung der ersten 48 h nach PTSMA erscheint die zuverlässige Identifikation von DDD-SM-Kandidaten möglich. Patienten mit <8 Punkten des vorgestellten Score haben ein äußerst geringes, solche mit >12 Punkten ein sehr hohes Risiko für einen permanenten AVB. In den verbleibenden Fällen kann unter prolongiertem Monitoring die Erholung der AV-Überleitung abgewartet und so die Zahl langfristig unnötiger DDD-SM-Implantationen verringert werden. Bei Pat. mit LSB erscheint die primäre Versorgung mit einem DDD-SM sinnvoll.

Perkutane transluminale septale Myokardablation bei hypertroph-obstruktiver Kardiomyopathie: Akutergebnisse bei 66 Patienten unter Berücksichtigung der Myokard-Kontrastechkardiographie

Background: In hypertrophic obstructive cardiomyopathy (HOCM) therapy, surgical myectomy and DDD pacemaker implantation are considered to be established extensions to medical treatment. As an alternative procedure for reducing the left ventricular outflow track gradient (LVOTG), percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion has been introduced. We report on the acute results and the short-term clinical course following 66 PTSMA interventions in symptomatic patients (pts.) with HOCM. Methods: In pts. who were symptomatic despite adequate drug therapy (31 women, 35 men; mean age 52.9 ± 15.0 years, range: 16–86) 66 PTSMA interventions were performed (4 pts. with a re-intervention). Septal branches were included by injection of 3.5±1.8 (1.5–11.0) ml ethanol (96%). In the first 30 pts. the target vessel was determined by probatory balloon occlusion (PBO) alone, in the following 36 by additional myocardial contrast echocardiography (MCE). In-hospital follow-up of LVOTG and clinical course were determined. Reults: The invasively determined LVOTG could be reduced by > 50% or eliminated in 54 interventions (82%) with a mean reduction from 71.2 ± 34.4 (4–174) to 18.0 ± 21.5 (0–105) mm Hg at rest and from 145.7 ± 42.3 (68–257) to 63.7 ± 49.3 (0–185) mm Hg post extrasystole (p < 0.0001). All pts. experienced angina pectoris with the first 24 hours. The creatine kinase peak was 690 ± 364 (201–1810) U/l after 11.0 ± 5.4 (4–24) hours. 45 pts. (68%) developed trifascicular block, requiring temporary, or in 9 cases (14%) permanent, (DDD) pacemaker implantation. Two pts. (3%) died 9 and 2 days after a successful intervention, due to uncontrollable ventricular fibrillation associated with betasympathomimetic and theophylline treatment for chronic obstructive pulmonary disease in one case, and fulminant pulmonary embolism in the other. The remaining pts. were discharged after 11.1 ± 4.6 (5–24) days, following an uncomplicated hospital course. The introduction of MCE was associated with a higher percentage of short-term success (92% vs. 70%, p < 0.015. Conclusion: PTSMA in HOCM is a promising non-surgical technique for septal myocardial reduction with a consecutive reduction of the LVOTG. MCE has shown to be a useful addition to PBO for selection of the target vessel. Possible complications are trifascicular blocks requiring permanent pacemaker implantation and tachycardiac rhythm disturbances. Prospective long-term observations of larger populations and a comparison with the established forms of therapy are necessary in order to determine the definitive significance of PTSMA. Hintergrund: Die chirurgische Myotomie-Myektomie und die DDD-Schrittmacherimplantation gelten als Therapieoptionen für medikamentös nicht hinreichend behandelbare Patienten (Pat.) mit hypertroph-obstruktiver Kardiomyopathie (HOCM). Als alternative nichtchirurgische Strategie wurde die perkutane transluminale septale Myokardablation (PTSMA) zur Reduktion der septalen Hypertrophie bzw. des Gradienten über dem linksventrikulären Ausflußtrakt (LVOTG) entwickelt. Wir berichten über Akutergebnisse und Hospitalverlauf der ersten 66 Patienten. Methoden: Bei 66 trotz Medikation symptomatischen Patienten (4 Pat. mit 2 Interventionen; 31 Frauen, 35 Männer; mittleren Alters 52,9& plusmn; 15,0 (16–86 Jahre) mit HOCM wurde die Indikation zur PTSMA gestellt. Die Intervention erfolgte durch Injektion von 3,5 ± 1,8 (1,5–11) ml 96%igen Alkohols. Bei den ersten 30 Interventionen wurde das Zielgefäß durch probatorische Ballonokklusion (PBO) ermittelt, bei den folgenden Eingriffen mittels zusätzlicher Myokard-Kontrastechokardiographie (MCE). Das hämodynamische Akutergebnis und der klinische Verlauf wurden erfaßt. Ergebnisse: Die invasiv gemessenen LVOTG konnten bei 54 Interventionen (82%) um mehr als 50% gesenkt oder ganz beseitigt werden mit einer Reduktion von im Mittel 71,2 ± 34,4 (4–174) auf 18,0 ± 21,5 (0–105) mm Hg in Ruhe bzw. von 145,7 ± 42,3 (68–257) auf 63,7 ± 49,3 (0–185) mm Hg postextrasystolisch (p < 0,0001). Alle Patienten klagten über mäßige, pektanginöse Beschwerden. Der CK-Gipfel betrug 690 ± 364 (201–1810) U/l nach 11,0 ± 5,4 (4–24) h. Ein trifaszikulärer Block entwickelte sich nach 45 Eingriffen (68%); in 9 Fällen (14%) mußte ein permanenter DDD-Schrittmacher implantiert werden. Zwei Patienten (3%) verstarben 9 bzw. 2 Tage nach primär effektiver PTSMA infolge intraktablen Kammerflimmerns, assoziiert mit einer beta-mimetischen und Theophyllin-Therapie wg. schwerer chronischer obstruktiver Atemwegserkrankung (COLD) in einem und an einer fulminanten Lungenembolie im zweiten Fall. Die übrigen Patienten wurden nach 11,1 ± 4,6 (5–24) die bzw. unauffälligem Hospitalverlauf entlassen. Die Einführung der MCE war mit einer höheren Rate akut erfolgreicher Eingriffe assoziiert (92% vs. 70%, p < 0,015). Schlußfolgerung: Die PTSMA ist eine vielversprechende Option für medikamentös nicht hinreichend behandelbare Patienten mit HOCM. Zur Auswahl des Zielgefäßes hat sich die MCE als Zusatz zur PBO als hilfreich erwiesen. Komplikationsmöglichkeiten sind vor allem bradykarde (aufgrund einer permanenten trifaszikulären Blockierung mit der Notwendigkeit der DDD-Schrittmacher-Implantation) Rhythmusprobleme. Langzeitbeobachtungen, möglichst in Form eines prospektiv angelegten Registers und bei größeren Patientengruppen, sind notwendig zur Definition des Stellenwerts im Vergleich zu den etablierten Behandlungsverfahren.

Angeborene Herzfehler und erworbene Herzklappenfehler in der Schwangerschaft

Zusammenfassung.Hintergrund: Die jährliche Zahl schwangerer Herzfehlerpatientinnen beträgt in Deutschland etwa 6 000 (jede 130. Schwangerschaft). Die voraussehbaren hämodynamischen Veränderungen in der Schwangerschaft erlauben in der Mehrzahl der Fälle eine recht zuverlässige Vorhersage des Schwangerschaftsverlaufs für Mutter und Kind. Folgende fünf Aspekte sind von beträchtlicher klinischer Bedeutung. Unkorrigierte angeborene Herzfehler: Patientinnen mit nicht korrigierbaren komplexen Herzfehlern, einer nach Palliationsoperation persistierenden myokardialen Insuffizienz oder beträchtlichen pulmonalvaskulären Widerstandserhöhungen sollte von einer Schwangerschaft abgeraten werden. Prätrikuspidale Kurzschlussverbindungen werden in der Schwangerschaft in aller Regel gut toleriert. In den seltenen Fällen einer deutlichen symptomatischen Verschlechterung ist der katheterinterventive Shuntverschluss heute Therapie der Wahl. Bei Patientinnen mit Ventrikelseptumdefekt oder persistierendem Ductus Botalli liegt in aller Regel ein flussbegrenzender Defekt vor, der sich im Verlauf einer Schwangerschaft meist nicht negativ auswirkt. Bei unbehandelten Aortenisthmusstenosen sind in 2,3% der Fälle schwere Hypertonien, myokardiale Dekompensationen, Aortendissektionen und zerebrale Blutungen berichtet worden, deren Prävention spezifische Beratung und Therapie erfordert. Korrigierte angeborene Herzfehler: Die Gefährdung von Mutter und Kind ist nach Korrekturoperationen einer Fallotschen Tetralogie vom Korrekturergebnis abhängig. Das Risiko erscheint gut abschätzbar. Bei komplexen zyanotischen Vitien besteht ein deutlich erhöhtes maternales Risiko bezüglich myokardialen Pumpversagens, thromboembolischer Komplikationen, komplexer Arrhythmien und Endokarditiden. Die Inzidenz fetaler Aborte, Frühgeburten, Unreife bei der Geburt sowie kongenitaler Fehlbildungen beträgt > 50%. Erworbene Herzklappenfehler: Aufgrund der Schwangerschaftsphysiologie verschlechtert sich die hämodynamische Situation bei Mitralstenosen regelhaft. Patientinnen mit Klappenöffnungsflächen < 1,5 cm2 tolerieren diese Schwangerschaftsbedingungen häufig nicht. Sind die begrenzten Möglichkeiten einer medikamentösen Therapie erschöpft, ist die perkutane Ballonvalvulotomie heute Therapie der Wahl. Die in Kompetenzzentren erzielten Behandlungsergebnisse sind außerordentlich günstig. Die schwangerschaftstypische periphere Vasodilatation und Frequenzerhöhung führen dazu, dass die hämodynamischen Auswirkungen einer Mitral- und Aorteninsuffizienz während der Schwangerschaft in aller Regel nicht aggraviert werden. Aortenklappenstenosen sind bei Schwangeren außerordentlich selten. Der transaortale Blutfluss und Gradient nehmen im Verlauf der Schwangerschaft aufgrund der relativ verlängerten Systolendauer ab. Die linksventrikuläre Wandspannung nimmt dagegen zu, so dass trotz Abnahme des Gradienten eine myokardiale Dekompensation resultieren kann. Hypertrophe Kardiomyopathie: Der Verlauf gestaltet sich meist günstig. Eine präexistente Herzinsuffizienz wird bei etwa 20% der Patientinnen in der Schwangerschaft aggraviert. Besonders schlecht toleriert werden Vorhofflimmerepisoden und supraventrikuläre Tachykardien. Beide können Mutter und Fetus gefährden. Orale Antikoagulation: Die möglichen Antikoagulationsstrategien sind mit einem unterschiedlich hohen maternalen und fetalen Risiko verbunden. Bei gegebener Indikation ist die ununterbrochene orale Antikoagulation mit Phenprocoumon mit dem geringsten Risiko für die Mutter, die Beendigung jeglicher Antikoagulation mit dem geringsten Risiko für das ungeborene Kind verbunden. Einzelentscheidungen sind schwierig und sollten in die Hand eines erfahrenen Kompetenzzentrums gegeben werden.Abstract.Background: In Germany, about 6,000 pregnancies in women with grown-up congenital heart disease or acquired valvular lesions are expected per year. The pregnancy-related physiology is characterized by a 50% increase in plasma volume and a 25% increase in erythrocyte volume. The cardiac output increases by 40% due to 30% increase in stroke volume and 10% increase in heart rate during the first half, and 10% increase in stroke volume but 30% increase in heart rate during the second half of pregnancy. As a consequence of the decrease of systemic vascular resistance, the systolic and, even more, the diastolic blood pressures are reduced during approximately the first 20 weeks of pregnancy. Uncorrected Congenital Lesions: Women with uncorrectable congenital heart disease, congestive heart failure (NYHA III and IV) despite optimized medical treatment after palliative surgery, or pulmonary vascular resistances > 800 dyn × s × cm−5 should be advised against pregnancy. The presence of congestive heart failure or persistent cyanosis in the mother are the most important predictors of fetal hypoxia. Patients with pretricuspid shunts (e.g., atrial septal defect [ASD]) are at low risk of a hemodynamic deterioration or first onset of arrhythmias. In the rare case of a marked clinical deterioration, catheter-based closing of the shunt is the first-line treatment. Also, ventricular septal defects and persistent ducti arteriosi are usually well tolerated during pregnancy, as they are highly resistant to flow. In some cases, arrhythmias may occur. The prognosis is less favorable, if myocardial compromise has already been present before pregnancy. The fatal complication rate correlates closely with the degree of congestive heart failure. In aortic coarctation, development of severe hypertension, myocardial decompensation, aortic dissection, and cerebral hemorrhage have been reported in 2.3% of cases. To prevent aortic dissection and rupture of cerebral vascular aneurysms, patients should be advised to reduce their physical activity and have their blood pressure controlled closely. If, during pregnancy, a therapeutic intervention is inavoidable, stent placement is the therapy of choice. The maternal complication rate is low in pulmonary artery stenosis. Hemodynamically significant stenoses should be treated before pregnancy. In the rare case of progressive right heart failure or cyanosis during pregnancy, balloon valvotomy is the first-line therapeutic option. Congenital Heart Disease with Prior Palliation: Women with incomplete correction of a tetralogy of Fallot or significant residual gradients or shunts carry a particular risk of myocardial deterioration. A maternal hematocrit > 60%, an arterial O2 saturation < 80%, markedly elevated right ventricular pressures, and the former presentation of syncopes are indicators of a poor prognosis. Fatal complication rates have been reported in 3–17% of cases. Other cyanotic lesions have been linked with a poor maternal and fetal prognosis. A 32% incidence of severe cardiovascular complications (pump failure, thromboembolic events, life-threatening arrhythmias, infective endocarditis) has been reported during 96 pregnancies of women with cyanotic heart disease. In addition, the frequency of abortions, premature birth, fetal distress, and congenital malformation of the child was 57%. Acquired Valve Lesions: Mitral stenosis is the lesion that most frequently requires therapeutic intervention during pregnancy, as the transmitral flow increases and time of diastole decreases during pregnancy due to the increase in cardiac output and heart rate. A consequent increase in mean pulmonary artery pressure by approximately 50% and a deterioration by one to two NYHA classes must be expected. While patients with a mitral orifice area > 1.5 cm2 can usually be treated medically, more advanced mitral stenoses often require percutaneous mitral balloon valvotomy, a procedure with a very low complication rate in experienced centers. A chronic mitral or aortic regurgitation without jeopardized myocardial function is usually well tolerated during pregnancy, as the drop in peripheral vascular resistance results in a favorable left ventricular impedance, which reduces the transmitral regurgitant fraction and improves left ventricular antegrade ejection. Moreover, the increase in heart rate limits diastolic transaortic regurgitation. Hemodynamically advanced aortic stenosis is rare among patients in child-bearing age. The hemodynamic changes during pregnancy result in a decrease of the transaortic flow per time and thus in a decrease of the transaortic pressure loss. On the other hand, myocardial wall stress and oxygen consumption are significantly increased. If aortic valve orifice area is > 1.5 cm2, the hemodynamic situation is usually well tolerated during pregnancy. In the case of more advanced aortic stenosis, there is a considerable risk of myocardial decompensation. The development of symptoms such as dyspnea, near syncopes or syncopes, and arrhythmias are indicators of a complicated course. If treatment is unavoidable, aortic valve replacement is the therapy of choice. Oral Anticoagulation: With respect to anticoagulation during pregnancy, there is an ongoing debate about the potential risk and benefit of phenprocoumon, standard heparins, and low molecular heparins. Withdrawal of any anticoagulation results in the most favorable fetal outcome, oral anticoagulation throughout pregnancy in the best prognosis for the mother. An individual approach by an experienced center taking all therapeutic options into account is probably the best strategy.

Early (Three-Month) Results of Percutaneous Mitral Valvotomy With the Inoue Balloon in 1,123 Consecutive Patients Comparing Various Age Groups

109 (76%) 667 (80%) 128 (88%) 904 (80%) Rheumatic fever history 49 (34%) 320 (38%) 46 (32%) 415 (37%) Atrial fibrillation 23 (16%) 443 (53%) 101 (69%) 567 (50%) Previous surgical commissurotomy 13 (9%) 103 (12%) 11 (8%) 127 (11%) MR grades I-II 51 (35%) 349 (42%) 60 (41%) 460 (41%) Previous cerebral and/or peripheral embolism 12 (8%) 159 (14%) 48 (33%) 219 (20%)

Analysis of Right Heart Blood Flow from Contrast Patterns on the Echocardiogram

Flow velocity measurements are common diagnostic procedures during invasive hemodynamic studies [1, 2]. In noninvasive cardiovascular investigation, however, flow velocity analysis is still a major problem, though highly sophisticated Doppler systems have been applied for flow measurements with increasing success [2, 3, 4]. Contrast echocardiography has been used for the detection of shunts and of tricuspid regurgitation. The advantage of one-dimensional (1D) echocardiography is the excellent time resolution, routinely used for the calculation of the mitral valve EF-slope and the slopes of other moving structures. Blood flow lines can be visualised on M-mode echocardiograms by injection of ultrasound-reflecting substances or micro-spheres. The slope and direction of these flow lines can be analysed in order to obtain the component of flow direction and velocity along the main transducer axis [6, 7]. As far as we know, no other groups have published experiences with the technique described in this study.