Dirk Skowasch

Usefulness of Sleep-Disordered Breathing to Predict Occurrence of Appropriate and Inappropriate Implantable-Cardioverter Defibrillator Therapy in Patients With Implantable Cardioverter-Defibrillator for Primary Prevention of Sudden Cardiac Death

Advanced heart failure (HF) is associated with severe sleep-disordered breathing (SDB). In addition, most patients with HF are treated with an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death. The incidence of ICD therapy in such a patient cohort with SDB has never been investigated. The present study sought to determine the effect of SDB on the incidence of appropriate and inappropriate ICD therapy in patients with a categorical primary prevention ICD indication. A total of 133 consecutive ICD patients with New York Heart Association class II-III HF and depressed left ventricular function (≤35%) with no history of ventricular arrhythmia underwent a sleep study before ICD implantation and were followed for 24 ± 8 months, prospectively. A relevant SDB was defined as an apnea-hypopnea index of ≥10 events/hour. Of these 133 patients, 82 (62%) had SDB. Overweight (body mass index >29.1 vs 24.7 kg/m(2); p <0.001) was identified as the only independent risk factor for SDB. Appropriate ICD therapy intervention was significantly greater among patients with SDB than among patients without SDB (54% vs 34%, p = 0.03). Inappropriate ICD therapy intervention was documented more often in patients with SDB (n = 24 [29%] vs 7 [14%]; p = 0.04). An apnea-hypopnea index >10 events/hour was an independent predictor of appropriate ICD therapy on multivariate analysis (odds ratio 2.5, 95% confidence interval 1.8 to 4.04; p = 0.01). In conclusion, the present study is the first trial exploring the effect of SDB on the incidence of appropriate and inappropriate ICD therapy in patients with HF with a primary prevention indication. These results indicate that a preimplantation sleep study will identify patients with HF prone to receive appropriate and inappropriate ICD therapy.

Pulmonary hypertension: Hemodynamic evaluation. Updated Recommendations of the Cologne Consensus Conference 2011

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the invasive hemodynamic evaluation of pulmonary hypertension. This manuscript describes in detail the results and recommendations of the working group which were last updated in October 2011.

Effect of endobronchial valve therapy on pulmonary perfusion and ventilation distribution.

Introduction Endoscopic lung volume reduction (ELVR) is an emerging therapy for emphysematous COPD. However, any resulting changes in lung perfusion and ventilation remain undetermined. Here, we report ELVR-mediated adaptations in lung perfusion and ventilation, as investigated by means of pulmonary scintigraphy. Methods In this observational study, we enrolled 26 patients (64.9±9.4 yrs, 57.7% male) with COPD heterogeneous emphysema undergoing ELVR with endobronchial valves (Zephyr, Pulmonx, Inc.). Mean baseline FEV1 and RV were 32.9% and 253.8% predicted, respectively. Lung scintigraphy was conducted prior to ELVR and eight weeks thereafter. Analyses of perfusion and ventilation shifts were performed and complemented by correlation analyses between paired zones. Results After ELVR, target zone perfusion showed a mean relative reduction of 43.32% (p<0.001), which was associated with a significant decrease in target zone ventilation (p<0.001). Perfusion of the contralateral untreated zone and of the contralateral total lung exhibited significant increases post-ELVR (p = 0.002 and p = 0.005, respectively); both correlated significantly with the corresponding target zone perfusion adaptations. Likewise, changes in target zone ventilation correlated significantly with ventilatory changes in the contralateral untreated zone and the total contralateral lung (Pearson’s r: −0.42, p = 0.04 and Pearson’s r: −0.42, p = 0.03, respectively). These effects were observed in case of clinical responsiveness to ELVR, as assessed by changes in the six-minute walk test distance. Discussion ELVR induces a relevant decrease in perfusion and ventilation of the treated zone with compensatory perfusional and ventilatory redistribution to the contralateral lung, primarily to the non-concordant, contralateral zone.

Diagnostic value of speckle-tracking echocardiography in confirmed cardiac sarcoidosis

Sirs: Sarcoidosis is a chronic, non-caseating granulomatous disease of unknown origin that can affect any organ. Given the heterogeneity of sarcoidosis per se and cardiac sarcoidosis (CS), in particular [1, 2], major efforts are undertaken to identify cardiac sarcoid that may initially be clinically silent and may first manifest as sudden cardiac death. Since the use of advanced imaging modalities, such as positron emission tomography and cardiovascular magnetic resonance (CMR) imaging, is restricted due to their limited availability and costliness, alternative imaging techniques that allow for a reliable, and timely CS diagnosis demand attention. Two-dimensional (2D) speckletracking echocardiography facilitates the assessment of regional and global myocardial deformation properties [3]. Nonetheless, the question of its potential to visualize CSinduced myocardial dysfunction remains unresolved. To define its validity for the diagnosis of cardiac sarcoidal involvement, we performed speckle-tracking analysis of both CS-positive and CS-negative patients. Study population comprised 60 patients with histologically proven sarcoidosis of whom 19 patients suffered from cardiac sarcoid involvement, whereas the remaining 41 patients did not. CS-presence and CS-absence were defined on the basis of prior CMR results. At the time of CMR examination, patients underwent complementary 2D transthoracic echocardiography. Echocardiographic data were digitized and transferred to a commercially available medical workstation (TomTec Imaging Systems GmbH, Unterschleissheim, Germany). An apical four chamber view was offline speckle-tracking-analyzed. Regional strain evaluation was conducted by each ventricle’s segmentation into an apical, mid-ventricular, and basal region. Statistical analysis was performed using the SPSS Software Version 23.0 (Armonk, NY, USA). Bonferroni correction was applied for adjustment for multiple comparisons. Receiver operating characteristic (ROC) curve analysis was conducted to describe the predictive value of strain measurements. In ten consecutive patients, interobserver agreement and intra-observer agreement of strain measurement were tested by intraclass correlation coefficient; a coefficient [0.8 indicated a good reliability. A two-tailed p value of \0.05 was considered statistical significant. Table 1 summarizes the study populatiońs demographic, echocardiographic, and CMR characteristics. Evaluation of global and regional biventricular deformation properties derived from 2D longitudinal strain imaging revealed impairment of longitudinal performance in CS-positive patients as compared to CS-negative individuals. Specifically, the left ventricular (LV) global, medial septal, and apical septal longitudinal strain were significantly reduced in and correlated with CS-presence (p = 0.009, p = 0.007, p = 0.02, respectively; Table 1). After adjustment for multiple comparisons, the global and medial septal longitudinal strain persistently differed between groups, whereas the apical septal longitudinal strain did not (p = 0.04, p = 0.04, and p = 0.12, respectively). Comparative ROC analysis of the global and medial septal measures identified the LV global longitudinal strain to have the highest predicted value for the diagnosis of CS: the area under the curve was 0.72 (95 % CI: 0.56–0.87; p\ 0.01) and C. Pizarro and F. Kluenker contributed equally to this work.

Impact of endoscopic lung volume reduction on right ventricular myocardial function.

Introduction Endoscopic lung volume reduction (ELVR) provides a minimally invasive therapy for patients with severe lung emphysema. As its impact on right ventricular (RtV) function is undefined, we examined the extent of RtV functional changes following ELVR, as assessed by use of speckle tracking-based RtV deformation analysis. Methods We enrolled 32 patients with severe emphysematous COPD scheduled for bronchoscopic LVR using endobronchial valves (Zephyr, PulmonX, Inc.), comprising 16 matched clinical responders and 16 non-responders. Echocardiography was conducted one day prior to ELVR and at an eight-week postprocedural interval. Results Patients were predominantly of late middle-age (65.8±8.7yrs), male (62.5%) and presented advanced COPD emphysema (means FEV1 and RV: 32.6% and 239.1% of predicted, respectively). After ELVR, RtV apical longitudinal strain improved significantly in the total study cohort (-7.96±7.02% vs. -13.35±11.48%, p=0.04), whereas there were no significant changes in other parameters of RtV function such as RtV global longitudinal strain, TAPSE or pulmonary arterial systolic pressure. In responding patients, 6MWT-improvement correlated with a decrease in NT-proBNP (Pearson´s r: -0.53, p=0.03). However, clinical non-responders did not exhibit any RtV functional improvement. Discussion ELVR beneficially impacts RtV functional parameters. Speckle tracking-based RtV apical longitudinal strain analysis allows early determination of RtV contractile gain and identification of clinical responsiveness.

Volumetric and scintigraphic changes following endoscopic lung volume reduction

Bronchoscopic treatment of emphysema represents an emerging therapeutic modality for advanced emphysematous lung destruction in chronic obstructive pulmonary disease (COPD). Within the proposed techniques for endoscopic lung volume reduction (ELVR), a significant amount of experience exists for the placement of endobronchial valves (EBV) (Zephyr® valves; Pulmonx, Inc., Redwood City, CA, USA) targeting atelectasis of the treated, emphysematous lobe [1, 2]. However, post-procedural clinical improvement has also been documented in patients lacking lobar exclusion 3. While volumetric and density adaptations following ELVR have repeatedly been a focus [3, 4], the interaction of volume and perfusional/ventilatory changes remains unclear. In this observational study, we defined the extent of interdependency of ELVR-mediated volumetric and scintigraphic adaptations. EBV treatment reduces target lobe volume, ventilation and perfusion with consistent redistributive pattern http://ow.ly/C95Ue

Cardiovascular magnetic resonance imaging and clinical performance of somatostatin receptor positron emission tomography in cardiac sarcoidosis: CMR and SSTR PET in cardiac sarcoidosis

Cardiac affection constitutes a major limiting condition in systemic sarcoidosis. The primary objective of this study was to investigate the persistence rate of cardiac sarcoid involvement by cardiovascular magnetic resonance (CMR) imaging in patients diagnosed with cardiac sarcoidosis (CS). Moreover, we examined the additional insights into myocardial damages characteristics gained by somatostatin receptor scintigraphy.

Lower extremity and carotid artery disease in COPD.

In view of their common chronic inflammatory process, we sought to determine the linkage between peripheral artery disease and chronic obstructive pulmonary disease (COPD). 107 COPD patients (mean±sd age 64.6±10.4 years, 52.2% male) and 22 control smokers without previously diagnosed peripheral artery disease underwent standardised angiological examination for lower extremity artery disease (LEAD) and carotid artery disease. LEAD was significantly more prevalent in COPD patients than in controls (80.4% versus 54.5%, p=0.002). Among COPD patients, 57.0%, 12.2%, 10.3% and 0.9% were found to be in Fontaine stages I, IIA, IIB and III, respectively. As with carotid artery disease, its frequency increased from 36.4% in controls to 58.9% in COPD patients (p=0.003). Carotid plaque burden, LEAD Fontaine degrees as well as pulse wave index and ankle–brachial index manifested significant impairment over percentage predicted forced expiratory volume in 1 s (FEV1 % pred) (p=0.02, p<0.001, p=0.01 and p<0.001, respectively). Multivariate analysis revealed that COPD Global Initiative for Chronic Obstructive Lung Disease status was the strongest independent predictor for the presence of plaque in lower extremity arteries (odds ratio 1.63, 95% CI 1.19–2.25, p=0.003) and carotids (odds ratio 1.66, 95% CI 1.14–2.44, p=0.009). As compared with control smokers, peripheral artery disease is diagnosed in a sizeable proportion of COPD patients and exhibits significant distributive differences over FEV1 % pred that exceed the susceptibility conferred by common cardiovascular stressors. Undiagnosed lower extremity and carotid artery disease is common in COPD and aggravates over COPD GOLD stages http://ow.ly/w96f303lHTu

Nitinol stent insertion in tracheomalacia

A 69-year-old man was admitted to our hospital with progressive dyspnoea accompanied by inspiratory stridor. He presented a history of surgical aortic valve replacement 3 years previously, complicated by prolonged postoperative mechanical ventilation requiring percutaneous tracheostomy. Presently, bronchoscopy evidenced tracheomalacia (TM) with subtotal tracheal stenosis. CT scan confirmed long segment narrowing >20 mm of the upper trachea (figure 1). Operative retracheostomy resulted in repeated tube dislocation …

FKBP12+ S100+ Dendritic Cells as Novel Cellular Targets for Rapamycin in Post Stent Neointima

Background: Despite promising clinical results for rapamycin-eluting stents, the exact mechanism of action and cellular targets are not clear. Therefore, we determined the presence and spatiotemporal signal pattern of the rapamycin receptor FK506-binding protein FKBP 12 in minipig aortic segments after stent implantation. Methods: Male minipigs underwent bare metal stent implantation to aortic segments. At days 7, 14, 30, 60 and 90 after injury, arterial cross sections were analyzed by immunohistochemistry for FKBP12 and S100+ dendritic cells. Results: At day 7, about 25% of neointimal cells expressed FKBP12. In further time course signaling for FKBP12 decreased continuously and revealed two predilection regions at luminal and stented sites. Throughout the observation time, a significant portion of FKBP12+ cells coexpressed S100 marker. Conclusion: The rapamycin receptor FKBP12 is predominantly present in early neointima. Colocalisation of FKBP12 and S100 suggests that dendritic cells may be another important target for rapamycin actions.