Giuseppe D’Ancona

Correlation between the functional impairment of bone marrow-derived circulating progenitor cells and the extend of coronary artery disease

BackgroundBone marrow-derived circulating progenitor cells (BM-CPCs) in patients with coronary heart disease are impaired with respect to number and functional activity. However, the relation between the functional activity of BM-CPCs and the number of diseased coronary arteries is yet not known. We analyzed the influence of the number of diseased coronary arteries on the functional activity of BM-CPCs in peripheral blood (PB) in patients with ischemic heart disease (IHD).MethodsThe functional activity of BM-CPCs was measured by migration assay and colony forming unit in 120 patients with coronary 1 vessel (IHD1, n = 40), coronary 2 vessel (IHD2, n = 40), coronary 3 vessel disease (IHD3, n = 40) and in a control group of healthy subjects (n = 40). There was no significant difference of the total number of cardiovascular risk factors between IHD groups, beside diabetes mellitus (DM), which was significantly higher in IHD3 group compared to IHD2 and IHD1.ResultsThe colony-forming capacity (CFU-E: p < 0.001, CFU-GM: p < 0.001) and migratory response to stromal cell-derived factor 1 (SDF-1: p < 0.001) as well as vascular endothelial growth factor (VEGF: p < 0001) of BM-CPCs were reduced in the group of patients with IHD compared to control group. The functional activity of BM-CPCs was significantly impaired in patients with IHD3 as compared to IHD1 (VEGF: p < 0.01, SDF-1: p < 0.001; CFU-E: p < 0.001, CFU-GM: p < 0.001) and to IHD2 (VEGF: p = 0.003, SDF-1: p = 0.003; CFU-E: p = 0.001, CFU-GM: p = 0.001). No significant differences were observed in functional activity of BM-CPCs between patients with IHD2 and IHD1 (VEGF: p = 0.8, SDF-1: p = 0.9; CFU-E: p = 0.1, CFU-GM: p = 0.1). Interestingly, the levels of haemoglobin AIc (HbAIc) correlated inversely with the functional activity of BM-CPCs (VEGF: p < 0.001, r = −0.8 SDF-1: p < 0.001, r = −0.8; CFU-E: p = 0.001, r = −0.7, CFU-GM: p = 0.001, r = −0.6) in IHD patients with DM.ConclusionsThe functional activity of BM-CPCs in PB is impaired in patients with IHD. This impairment increases with the number of diseased coronary arteries. Moreover, the regenerative capacity of BM-CPCs in ischemic tissue further declines in IHD patients with DM. Furthermore, monitoring the level of BM-CPCs in PB may provide new insights in patients with IHD.

Percutaneous Treatment of Adult Isthmic Aortic Coarctation Acute and Long-Term Clinical and Imaging Outcome With a Self-Expandable Uncovered Nitinol Stent

Background—To present perioperative and long-term results of percutaneous treatment of adult isthmic coarctation of the aorta by means of a self-expandable closed-web uncovered nitinol stent (Sinus-XL, Optimed, Esslingen, Germany). Methods and Results—Preoperative, perioperative, and long-term clinical and computed tomographic angiography data were collected and analyzed prospectively. A total of 52 consecutive patients were treated with the Sinus-XL stent. Mean age was 36.6 (21–67) years, peak invasive trans–coarctation of the aorta gradient was 54.7±9.9 mm Hg, and upper body hypertension unresponsive to medical treatment was present in all patients. Mean stent diameter and length were 24.2 mm (22–28 mm) and 70.4 mm (40–80 mm), respectively. Eight patients (15.4%) required coarctation of the aorta predilatation. All patients underwent poststent dilatation with a noncompliant balloon. Postoperative peak gradient (3.3±2.5 mm Hg) was reduced significantly (P<0.001) and minimal aortic diameter was increased significantly (4.6±1.9 versus 18.6±2.5 mm; P<0.001). All patients were discharged home (mean hospitalization, 3.5 days). At follow-up (47.6 months; 12–84), 1 (1.9%) noncardiovascular mortality was reported. Aortic computed tomography confirmed the absence of stent collapse and secondary migration and documented stability in aortic diameter (18.3±2.7 mm). Thirty patients (57.7%) were completely weaned-off antihypertensive medications and their use dropped from 2.6 to 0.9 drugs/patient (P<0.001). Ankle-brachial pressure index increased from 0.75 to 0.98 (P<0.001). Conclusions—Adult coarctation of the aorta treatment by means of a self-expandable uncovered stent is safe and durable. The peculiar stent design maintains adequate localized radial strength over time with minimal trauma on the adjacent aortic wall and negligible device-related complications. Blood pressure control optimization is immediate and persistent even at long-term follow-up.

Percutaneous edge-to-edge mitral valve repair for recurrent mitral regurgitation after percutaneous mitral annuloplasty: towards a staged approach

Sirs: Although mitral valve (MV) repair remains the treatment of choice to treat severe mitral valve regurgitation (MR), there is still a plethora of patients that, in light of their complex comorbid profile, could be approached in a less invasive fashion [1]. Timely echocardiography evaluation of the valve anatomy and the regurgitation flow-dynamics are crucial to plan an adequate percutaneous repair strategy [2, 3]. In this context, the MR often results from an annular dilatation that leads to a decreased MV leaflets coaptation. The percutaneous transvenous MitraClip -System (MitraClip, Abbot, USA) has been recently introduced and popularized to mimic the ‘‘edge to edge’’ MV repair firstly described by Alfieri et al. The results of the EVEREST II trial have demonstrated that the procedure is safe and associated with improvements in clinical outcomes [4]. Implantation of a percutaneous transvenous mitral annuloplasty (PTMA) device to reduce the MV annular size has also been shown to be feasible and safe [5–7]. After percutaneous annuloplasty with the MONARC device (Edwards Lifesciences, Irvine, California), a 12-months reduction in MR by C1 grade was observed in 85 % of patients with baseline MR grade C3 [6]. We report on a 74-year-old multi-morbid female patient (EuroScore 24, STS 14) presenting with severe MR recurring 2 years after implantation of a MONARC device. The patient was admitted in our institution with increasing shortness of breath and signs of heart failure (New York Heart Association (NYHA) class III). Echocardiography revealed a reduced left ventricular ejection fraction (LVEF 43 %) secondary to ischaemic cardiomyopathy. A markedly eccentric MR grade 3 (type IIIb Capentier’s functional classification) was also reported. The MV annulus was measured 3.9 cm (lateral–medial) and 3.6 cm (anterior–posterior) with a MV orifice area (MVOA) of 6.9 cm. An interventional strategy to address the MR was planned after exacerbation of the heart failure picture in spite of maximal medical treatment. Percutaneous placement of the MitraClip to maximize MV leaflets cooptation and reduce MR was performed under general anaesthesia and with continuous twoand three-dimensional echocardiography and fluoroscopy imaging. After standard implantation of the first clip within the main jet area, the severity of MR was reduced to grade 1? to 2. A second clip was implanted parallel to the first one to eliminate the residual regurgitation. At the end of the procedure there was no mitral stenosis (mean gradient of 3 mm Hg, MVOA of 2.5 cm) and only a trivial MR. Notice that there was a significant reduction of the MV anterior–posterior annular dimension (2.3 cm postinterventional) and no changes in the latero-medial size (unchanged at 3.8 cm) (Fig. 1). The patient was discharged home on the 8th postoperative day in NYHA class I–II. A 6-month follow-up confirmed the clinical and echocardiographic improvement. To the best of our knowledge MitraClip therapy to treat recurrent MR after previous PTMA has never been described before. In fact, PTMA with an incomplete ring decreases the septal-lateral annular diameter [6]. MitraClip implantation can facilitate MV leaflets coaptation and indirectly decrease the anterior–posterior MV annulus L. Paranskaya G. D0Ancona C. A. Nienaber H. Ince (&) Department of Cardiology, Heart Center Rostock, University Hospital of Rostock, E-Heydemann-Str. 6, 18057 Rostock, Germany e-mail: hueseyin.ince@med.uni-rostock.de

New generation cardioverter-defibrillator lead with a floating atrial sensing dipole: Long-term performance

The study aim is to present the long‐term performance of a new generation implantable cardioverter defibrillator (ICD) electrode with floating atrial dipole (Linox S DX, Biotronik, Berlin, Germany).

Approach to Mitral Regurgitation Requiring Multiple MitraClips

The MitraClip is a percutaneous therapy for repairing severe MR in either degenerative or functional mitral regurgitation (MR). In the initial clinical experience with this therapy, one or two clips were used. However, with commercial use of the device, increasingly more complex anatomy has been treated with some cases requiring three or more clips. The use of multiple clips is highly dependent on valve anatomy, mechanism, and severity of MR. This chapter discusses the implantation strategy, technical considerations, and the potential pitfalls of using multiple clips in the use of the MitraClip therapy.