H. K. Schmidt

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.

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.

Improved coronary vasodilatatory capacity by H.E.L.P. apheresis: comparing initial and chronic treatment.

Abstract:  Hypercholesterolemia impairs endothelial function and subsequently decreases coronary vasodilatatory capacity. We examined the quantitative effects of one single LDL apheresis on vasodilatatory capacity. Using N‐13 ammonia as a tracer for dynamic quantitative positron emission tomography (PET), mean myocardial perfusion measurements were carried out before and 20 h later after LDL apheresis, both under resting conditions and after pharmacological vasodilatation with dipyridamole. LDL apheresis was carried out using the heparin induced extracorporeal LDL precipitation (H.E.L.P.) procedure. We examined 47 patients (12 women and 35 men), with angiographically‐proven coronary artery disease. All of them suffered from hypercholesterolemia. Of the patients, 35 received a chronic weekly H.E.L.P. procedure (group A), while H.E.L.P. procedure treatment was started for the first time in 12 patients, who were subsequently enrolled in a chronic apheresis program (group B). H.E.L.P. apheresis was combined with cholesterol lowering drugs in all patients. Both groups underwent positron emission tomography twice (prior to LDL apheresis and 20 h later). In group A, LDL cholesterol levels decreased from 175 ± 50 mg/dL to 60 ± 21 mg/dL immediately after H.E.L.P. (77 ± 25 mg/dL before the second PET). Corresponding values for fibrinogen levels were 287 ± 75 mg/dL to 102 ± 29 mg/dL (155 ± 52 mg/dL), minimal coronary resistance dropped from 0.56 ± 0.20 to 0.44 ± 0.17 mm Hg × 100 g × min/mL (P < 0.0001). Plasma viscosity decreased by 7.8%. In group B, LDL cholesterol decreased from 187 ± 45 mg/dL to 75 ± 27 mg/dL (85 ± 29 mg/dL) and fibrinogen from 348 ± 65 mg/dL to 126 ± 38 mg/dL (168 ± 45 mg/dL). Minimal coronary resistance was reduced from 0.61 ± 0.23 to 0.53 ± 0.19 mm Hg × 100 g × min/mL (P < 0.01). Plasma viscosity was observed to decrease by 7.6%. The strong LDL drop in patients under chronic H.E.L.P. treatment has a significant impact on coronary vasodilatatory capacity within 20 h leading to an improved overall cardiac perfusion. Nearly the same effect can be seen in patients after their first H.E.L.P. treatment. 

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.

Percutaneous Closure of Atrial Septal DefectsCLINICAL PERSPECTIVE

Background— Percutaneous closure of atrial septal defects is well established in children and adults and has been found to improve symptoms and positively influence right-heart remodeling. The aim of this study was to evaluate the efficacy and long-term outcome in adult patients older than 60 years. Methods and Results— The study population comprised 96 patients in the age group of 60 to 84 years. Percutaneous closure was performed effectively in all patients. Functional capacity according to New York Heart Association functional class and peak oxygen uptake (VO2max) in the cardiopulmonary exercise testing improved significantly after atrial septal defects closure, especially in patients with a pulmonary-to-systemic flow ratio >2. Echocardiographic measurements of the right ventricular end-diastolic diameter showed a significant decrease. No device-associated complications were observed, but in 16 patients, paroxysmal atrial fibrillation occurred after device implantation. Conclusions— Percutaneous atrial septal defects closure can be performed safely and with minimal risk even in elderly patients. They profit in terms of symptom reduction, improvement of exercise capacity, and right-heart remodeling. Received March 26, 2008; accepted February 11, 2009. # CLINICAL PERSPECTIVE {#article-title-2}Background—Percutaneous closure of atrial septal defects is well established in children and adults and has been found to improve symptoms and positively influence right-heart remodeling. The aim of this study was to evaluate the efficacy and long-term outcome in adult patients older than 60 years. Methods and Results—The study population comprised 96 patients in the age group of 60 to 84 years. Percutaneous closure was performed effectively in all patients. Functional capacity according to New York Heart Association functional class and peak oxygen uptake (VO2max) in the cardiopulmonary exercise testing improved significantly after atrial septal defects closure, especially in patients with a pulmonary-to-systemic flow ratio >2. Echocardiographic measurements of the right ventricular end-diastolic diameter showed a significant decrease. No device-associated complications were observed, but in 16 patients, paroxysmal atrial fibrillation occurred after device implantation. Conclusions—Percutaneous atrial septal defects closure can be performed safely and with minimal risk even in elderly patients. They profit in terms of symptom reduction, improvement of exercise capacity, and right-heart remodeling.

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.

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%)

[Acute aortic dissection (Stanford A) with pericardial tamponade--extension of the dissection after emergency pericardial puncture].

Die hämodynamische Beeinträchtigung bei akuter Aortendissektion (Stanford A) tritt durch einen akuten Volumenverlust, eine akute Aortenklappeninsuffizienz, gegebenenfalls durch ein Hämoperikard mit Tamponadebildung auf. Bei Auftreten des letzteren kann durch eine Perikardiozentese eine hämodynamische Stabilisierung erreicht werden. Sie ist jedoch erst bei verminderter Perfusion vitaler Organe indiziert. Durch Entlastung des Perikardergusses kann ein Druckgradient zwischen Dissektions- und Perikardraum geschaffen werden, der sowohl eine erneute hämodynamische Verschlechterung durch den Blutfluß in den Perikardraum als auch eine Ausweitung der Aortendissektion verursachen kann. Nach der Perikardiozentese sollte umgehend eine Operation erfolgen. In dem von uns geschilderten Fall ist es mit großer Wahrscheinlichkeit durch diesen Mechanismus, nach primär effektiver hämodynamischer Stabilisierung durch Perikardiozentese, zur erneuten Tamponade und Ausweitung der Aortendissektion gekommen. Durch die direkt nach invasiver Diagnostik erfolgte Operation konnte durch Gefäßprothesenimplantation eine Sanierung erzielt werden. The hemodynamic deterioration associated with acute aortic dissection (Stanford A) is caused by an acute loss of volume, acute aortic valve insufficiency, or possibly by hemopericardium with tamponade. In the latter case, a pericardiocentesis may restore hemodynamic stability. However, it is only indicated in the case of reduced perfusion of vital organs. The relief of the pericardial effusion can produce a pressure gradient between dissection and pericardial space, which again might cause a hemodynamic deterioration by the blood flow into the pericardial space as well as an extension of the aortic dissection. Following pericardiocentesis immediate surgery is indicated. In the present case, after a primarily effective hemodynamic stabilization by pericardiocentesis, this mechanism has very probably led to a repeated tamponade and extension of aortic dissection, which was successfully repaired by the implantation of a vascular prosthesis immediately following invasive diagnosis.

Borrelien-Myokarditis als seltene Differentialdiagnose des akuten Vorderwandinfarktes

An acute Lyme carditis affects about 0.3–4% of patients with Lyme borreliosis. The acute period of the disease may be associated with critical atrioventricular conduction abnormalities (complete heart block), supraventricular and ventricular arrhythmias as well a left ventricular failure. Normally, Lyme carditis is completely reversible. Therefore the prognosis largely depends on the management of the acute complications and early antibiotic therapy. Even if the symptoms are spontaneously reversible, antibiotic therapy should be applied to prevent a chronic cardiomyopathy and other manifestations of Lyme borreliosis. We report on a 47-year old patient with acute ECG changes initially suggesting an acute coronary syndrome. However, case history and the erythema migrans indicated an acute Lyme carditis which was confirmed serologically and by myocardial biopsy later. Eine akute Lyme-Karditis entwickelt sich in Europa bei etwa 0,3–4% aller an Borreliose erkrankter Patienten. Im akuten Krankheitsverlauf können lebensbedrohliche Reizleitungsstörungen (AV-Block III) auftreten. Auch supraventrikuläre und ventrikuläre Arrhythmien sowie ein akutes Pumpversagen mit kardiogenem Schock werden beobachtet. In der Regel heilt die Lyme-Karditis ohne Residuen aus, so dass die Prognose weitgehend vom Management der akuten Komplikationen und einer frühen Antibiotikatherapie abhängt. Auch bei spontaner Reversibilität der Symptome sollte eine Antibiotikatherapie durchgeführt werden, um die Entstehung einer chronischen Kardiomyopathie und anderer Manifestationen der Borreliose vorzubeugen.    Es wird über eine 47-jährige Patientin berichtet, bei der die akuten EKG-Veränderungen zunächst den Verdacht auf ein akutes Koronarsyndrom nahelegten. Anamnese und das typische Erythema migrans wiesen jedoch auf eine akute Borrelienmyokarditis hin, die sich später serologisch und myokardbioptisch bestätigen ließ.

[Myocardial perfusion under H.E.L.P. -apheresis. Objectification by PET].

Due to endothelial dysfunction (ED), coronary vasodilation capacity is reduced in patients with hypercholesterolemia. Cholesterol lowering may largely restore endothelial function. Currently, it is supposed that the onset of this therapeutic effect takes weeks or even months. However, by means of LDL apheresis, a significant LDL reduction may be achieved within hours. Dynamic quantitative positron emission tomography (PET) performed before and after LDL apheresis showed that mean global myocardial perfusion can be measured at rest and after pharmacological vasodilation with dipyridamole using N13 ammonia as tracer. A total of 35 patients (11 women and 24 men) with documented coronary heart disease and hypercholesterolemia underwent PET immediately prior to LDL apheresis and 18–20 hours thereafter. In addition to the decrease in LDL cholesterol (from 175±50 to 77±25 mg/dl) and fibrinogen (from 287±75 to 155±52 mg/dl), a significant improvement of myocardial blood flow under dipyridamole (177±59 vs 217±82 ml/min 100 g, p<0.0001), of coronary flow reserve (2.10±0.82 vs 2.62±1.02, p<0.0001) and of minimal coronary resistance (0.56±0.20 vs 0.44±0.17 mmHg 100 g min/ml, p<0.0001) were achieved. Plasma viscosity decreased only by 7.8%. Within 20 hours after single LDL apheresis a 20% improvement of coronary vasodilation capacity was noninvasively demonstrated and quantified. Die koronare Vasodilatationskapazität ist bei Hypercholesterinämie infolge der Endotheldysfunktion (ED) vermindert. Eine medikamentöse Cholesterinsenkung kann die ED weitgehend normalisieren. Es ist jedoch strittig, wie schnell dieser Effekt eintritt. Bisher wird ein Zeitintervall von Wochen bis Monaten angenommen. Mittels LDL-Apherese ist eine bedeutsame LDL-Senkung innerhalb von Stunden möglich. Die vor und nach LDL-Apherese durchgeführte dynamische quantitative Positronenemissionstomographie ermöglicht die Messung der gemittelten globalen Myokardperfusion in Ruhe und nach pharmakologischer Vasodilatation mittels Dipyridamol unter Verwendung von N-13-Ammoniak als Tracersubstanz. Bei 35 Patienten (11 Frauen und 24 Männer) mit dokumentierter koronarer Herzkrankheit und Hypercholesterinämie wurde unmittelbar vor der LDL-Apherese und innerhalb von 18–20 h danach eine Positronenemissionstomographie durchgeführt. Parallel zur Senkung des LDL-Cholesterins (von 175±50 auf 77±25 mg/dl) und des Fibrinogens (von 287±75 auf 155±52 mg/dl) konnte eine signifikante Verbesserung des myokardialen Blutflusses unter Dipyridamolstimulation (177±59 vs. 217±82 ml/min 100 g, p<0,0001), der koronaren Flussreserve (2,10±0,82 vs. 2,62±1,02, p<0,0001) und des minimalen koronaren Widerstands (0,56±0,20 vs. 0,44±0,17 mmHg 100g min/ml, p<0,0001) erreicht werden. Die Plasmaviskosität zeigte eine nur geringfügige Abnahme um 7,8%. Innerhalb von 20 Stunden konnte nach einmaliger LDL-Apherese an einem größeren Patientenkollektiv nichtinvasiv und quantitativ eine ca. 20%ige Verbesserung der koronaren Vasodilatationkapazität nachgewiesen werden.