Höpp Hw

Transcatheter closure of atrial septal defect and patent foramen ovale with the ASDOS device (a multi-institutional European trial)∗

A clinical trial was conducted to assess the feasibility, safety, and efficacy of the atrial septal defect (ASD) occlusion system for transcatheter closure of secundum ASD and patent foramen ovale (PFO) after episodes of cerebral embolism. Occlusion was attempted in 200 patients aged 1 to 74 years (mean 32). The procedure failed in 26 patients (13%); the device was retrieved through a catheter in 20 and through surgery in 6 patients. Procedure-related complications necessitating surgical removal of the device included device embolization in 2, device entrapment within the Chiari network in 1, frame fracture in 1, and perforation of atrial wall in 2. All 6 patients experienced an uneventful postoperative course. An additional 11 patients (6%) underwent surgical removal of the device during follow-up. There were 163 patients (81%) with an implanted ASD occlusion system at follow-up of from 6 to 36 months (mean 17). Thrombus formation around the device was detected by transesophageal echocardiography in 9 patients 1 to 4 weeks after implantation. One of these patients (who had a coagulation factor XII deficiency) suffered a cerebral thromboembolism. Late atrial wall perforation (5, 6, and 8 months after implantation) occurred in 3 adult patients. Infectious endocarditis developed in 2 adult patients (1%). No late device embolization and no atrioventricular valve injury occurred. An asymptomatic device frame fracture was found in 14% and frame deformity in 4% of all patients during the follow-up period of >230 patient-years. Immediately after closure, a moderate/large residual shunt remained in 8% and a small shunt in 29% of patients. After 1 year, a moderate/large shunt was present in 2% and a small one in 26% of patients. During a total follow-up of 49 patient-years, only 1 of 46 patients with PFO had a transient neurologic event after the closure. The study indicates that patients with centrally situated secundum ASD and those with PFO after cerebral embolism can be treated with this system with a high success rate and an acceptable morbidity.

Hypertension guidelines and their limitations--the impact of physicians' compliance as evaluated by guideline awareness.

Objective The initial step of an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of new recommendations by the physicians themselves. This guideline awareness of the physicians has never been evaluated in detail. Design The awareness of content of current recommendations in hypertension diagnosis, treatment and treatment control was therefore assessed in primary care physicians using a questionnaire. The guidelines of the German Hypertension Society were used as the reference standard. Participants A total of 24 899 German physicians, including all internists, all cardiologists and 22% of general practitioners were contacted in a nationwide survey. Main outcome measures The number of answers in agreement with the guideline was used as a measure of guideline awareness. Adequate awareness of content of guideline recommendations was defined as the correct answer to five out of eight questions; the correct answers had to include the appropriate definition of hypertension. Results The analysis was based on 11 547 returned questionnaires (47.1%). An adequate guideline awareness was found in 23.7% of the total study population, especially in 37.1% of cardiologists, in 25.6% of internists and in 18.8% of general practitioners. While the guideline awareness was significantly influenced by the duration of private practice, regional and municipal factors had only minor influence on the results. Conclusion The impact of hypertension guidelines on actual medical knowledge is modest. Thus, the information strategies about current treatment guidelines must be improved and tailored to the needs of physicians in clinical practice to ultimately improve patient care.

Coronary plaque morphology affects stent deployment: Assessment by intracoronary ultrasound

The purpose of this study was to evaluate the changes in arterial wall morphology induced by coronary stent implantation and the influence of plaque morphology on stent expansion by intravascular ultrasound. Intravascular ultrasound imaging was performed in 25 lesions before and after Palmaz-Schatz stent implantation. In the 25 lesions with ultrasound images before and after stent deployment angiographic percent diameter stenosis decreased from 71% +/- 11% to 6% +/- 14%. By ultrasound there was a gain in luminal area from 2.0 mm2 +/- 1.5 mm2 to 6.6 mm2 +/- 2.1 mm2 owing to gain in external elastic membrane area of 2.5 mm2 +/- 1.7 mm2 and reduction of plaque area of 2.1 mm2 +/- 1.7 mm2. Calcified lesions (n = 8) showed significantly less relative luminal gain (218% +/- 128% vs. 421% +/- 276%, P = .01), and stent expansion was significantly less symmetric (minimal/maximal stent diameter 0.8 +/- 0.1 vs. 0.9 +/- 0.1, P = .002) as compared to non-calcified lesions (n = 17). The difference in lumen area within the stent between the previously stenotic area and the ends of the stent was significantly larger in calcified lesions as compared to non-calcified lesions (29 +/- 28% vs. 8 +/- 23%, P = .03). Both vessel stretch and plaque reduction contribute to the luminal gain after coronary stenting. Calcified lesions interfere with optimal stent expansion.

Noninvasive beat-by-beat registration of ventricular late potentials using high resolution electrocardiography

We have developed a new high resolution ECG equipment for recording cardiac microvolt potentials from the body surface. Noise reduction has been achieved by specially designed suction electrodes, by spatial averaging of the electrocardiograms from four electrode pairs, using extremely low noise amplifiers, by performing registrations within a Faraday cage, and by teaching the patient to relax during end expiratory breath holding. Fourteen young males (controls) and 30 patients with various cardiac diseases (27 with CHD) were studied. In normals ventricular late potentials were not seen, but in 12/30 patients clearcut diastolic potentials were found. In 7/12 patients with positive findings, late potentials appeared beat-by-beat, in 5/12 patients those signals occurred intermittently, in 11/30 patients questionably, and in the remaining 5/30 patients no late potentials were recorded. One patient with the Romano-Ward syndrome revealed phases with stable beat-by-beat and intermittently occurring ventricular late potentials. These results demonstrate the feasibility of continuous non-invasive recording of ventricular late potentials, whose clinical and prognostic significance remains to be established.

Cardiac involvement during and after malaria

SummaryIn 22 patients without a previous history of cardiac disease, we prospectively evaluated cardiac involvement during acute malaria and 9±5 months after recovery using non-invasive methods including resting electrocardiogram (ECG) and two-dimensional (2D) echocardiography. During the acute phase ECG abnormalities were common (5/22); pericardial effusion was found in 2 patients and global left ventricular hypokinesia in 1 patient infected with Plasmodium falciparum. At a follow-up of 19 patients, the resting ECG and echocardiography were normal or had normalized in all patients. The results of our study suggest that persistent cardiac damage following malarial infection seems to be rare; however, further trials in a larger patient population are needed to confirm our findings.

Vascular remodeling in atherosclerotic coronary arteries is affected by plaque composition.

BackgroundNarrowing of lumen in atherosclerotic lesions is determined not solely by accumulation of plaque but also by constrictive or expansive vascular remodeling. Underlying mechanisms and determinants of these bidirectional processes are not known. ObjectivesTo elucidate the response of vascular remodeling to progressive atherosclerosis by analyzing its potential association with composition of plaque. MethodsSeventy patients with 77 de‐novo coronary artery lesions underwent intravascular ultrasound imaging before coronary intervention. Target lesions were defined as soft, fibrous/mixed, and calcified plaques. Quantitative measurements of area of lumen (A L ), total area of vessel (A TV ) and area of plaque (A P  = A TV  – A L ) were performed at the lesion site and at the proximal and distal reference sites. Remodeling was determined by using a remodeling index [I R  =  (stenosis of A TV /mean reference A TV ) × 100]. ResultsOverall vascular remodeling was balanced with a mean remodeling index of 100.2 ± 19.3% and a high interlesion range (60.2–152.4%). The remodeling index for soft lesions was significantly higher than those for fibrous/mixed and calcified lesions (110 ± 18.8 versus 96.2 ± 14.4 and 85.9 ± 15.1%, P  < 0.01). Calcified lesions exhibited lower remodeling indexes than did uncalcified lesions (85.9 ± 15.1 versus 104.6 ± 18.4%, P  < 0.01). ConclusionsProcesses involved in vascular remodeling are affected by composition of plaque insofar as there is a higher prevalence of constrictive remodeling among calcified plaques and a higher prevalence of expansive remodeling among soft lesions. These findings indicate that constrictive remodeling is a late manifestation in atherogenesis. Future studies are warranted in order to enhance the understanding of progression of atherosclerosis, and of mechanisms of vascular remodeling and their impacts on interventional therapy.

Comparison of angioscopic, intravascular ultrasonic, and angiographic detection of thrombus in coronary stenosis

Coronary angioscopy, intravascular ultrasound, and angiography were compared in 20 patients regarding their sensitivity and specificity in the detection of thrombus. Although all imaging procedures demonstrate a high specificity, only coronary angioscopy has a sensitivity high enough to provide sufficient evidence of thrombus, even in patients with stable angina.

Thrombus formation after transcatheter closure of atrial septal defect

Thrombotic layers and/or atrial thrombi were detected by transesophageal echocardiography as a usual finding after transcatheter closure of atrial septal defects with the ASDOS device. The size of the thrombotic structures regularly decreased within 6 months without any clinical signs of embolization.

Increased expression of C-reactive protein and tissue factor in acute coronary syndrome lesions Correlation with serum C-reactive protein, angioscopic findings, and modification by statins

BACKGROUND Serum C-reactive protein (CRP) is a strong risk predictor of cardiovascular events, and tissue factor (TF) plays a central role in thrombus formation of advanced atherosclerotic plaques. Aim of the present study was to quantify in situ CRP and TF in coronary atherectomy specimens associated with acute coronary syndromes (ACS) or stable angina (SA). In addition, the effect of statin treatment on both intimal determinants was analyzed. METHODS AND RESULTS Serial sections from atherectomy probes retrieved from coronary primary target lesions of 42 ACS and 70 SA patients were examined for CRP and TF expression using immunostaining. CRP and TF intimal expression was consistently higher in ACS lesions and a positive correlation between both determinants was detected. In both subgroups intimal staining intensity of CRP but not TF was strongly associated with serum CRP levels. Using angioscopy, complex plaques revealed a higher intimal CRP and TF expression than white/yellow plaques. Both CRP and TF were consistently lower expressed in target lesions of patients with pre-existing statin treatment. CONCLUSIONS CRP and TF expression is markedly increased in plaques derived from patients with ACS as compared to SA patients. Statin treatment appears to reduce vascular expression of CRP and TF.

Compliance of a cobalt chromium coronary stent alloy – the COVIS trial

BackgroundCobalt chromium coronary stents are increasingly being used in percutaneous coronary interventions. There are, however, no reliable data about the characteristics of unfolding and visibility of this stent alloy in vivo. The aim of this study is to compare cobalt chromium coronary stents with conventional stainless steel stents using intracoronary ultrasound.MethodsTwenty de novo native coronary stenoses ≤ 20 mm in length (target vessel reference diameter ≥ 2.5 and ≤ 4.0 mm) received under sequential intracoronary ultrasound either a cobalt chromium stent (Multi-Link Vision®; n = 10) or a stainless steel stent (Multi-Link Zeta®; n = 10).ResultsFor optimal unfolding, the cobalt chromium stent requires a higher balloon deployment pressure (13.90 ± 2.03 atm) than the stainless steel stent (11.50 ± 2.12 atm). Furthermore, the achieved target vessel diameter of the cobalt chromium stent (Visibility-Index QCA/IVUS Multi-Link Vision®1.13 / Multi-Link Zeta® 1.04) is more easily overrated by Quantitative Coronary Analysis.ConclusionThese data indicate that stent material-specific recommendations for optimal implantation pressure and different stent material with an equal design should both be considered in interpreting QCA-analysis.