Lothar Faber

Sleep-disordered breathing in patients with symptomatic heart failure A contemporary study of prevalence in and characteristics of 700 patients

Evaluation of the prevalence and nature of sleep‐disordered breathing (SDB) in patients with symptomatic chronic heart failure (CHF) receiving therapy according to current guidelines.

Percutaneous Transluminal Septal Myocardial Ablation in Hypertrophic Obstructive Cardiomyopathy Results With Respect to Intraprocedural Myocardial Contrast Echocardiography

BACKGROUND Percutaneous transluminal septal myocardial ablation (PTSMA) has been introduced as an alternative procedure for reducing the left ventricular outflow tract gradient (LVOTG) in hypertrophic obstructive cardiomyopathy. We report on the acute and mid-term results in 91 symptomatic patients with respect to intraprocedural myocardial contrast echocardiography (MCE). METHODS AND RESULTS PTSMA was intended for 46 women and 45 men (54.1+/-15.5 years). In 2 patients, the intervention could not be completed. In the first 30 patients the target vessel was determined by probatory balloon occlusion alone and in the remainder by additional intraprocedural MCE. Resting LVOTG was reduced from 73.8+/-35.4 to 16.6+/-18.1 and nostextrasystolic LVOTG from 149.3+/-42.5 to 61. 9+/-43.0 mm Hg (P<0.0001 each). In 10 (11%) patients, permanent DDD pacemaker implantation was necessary. Two (2%) patients died, 1 from ventricular fibrillation associated with treatment for chronic obstructive pulmonary disease after 9 days and 1 from fulminant pulmonary embolism after 2 days. After 3 months, mean New York Heart Association class was reduced from 2.8+/-0.6 to 1.1+/-1.0 (P<0.0001). The LVOTG remained reduced to 14.6+/-25.5 mm Hg at rest and 49. 1+/-48.7 mm Hg (P<0.0001 each). Four patients underwent successful repeat PTSMA. Determination of the target vessel by MCE was associated with a higher rate of acute (92% vs 70%; P<0.01) and mid-term (94% vs 64%; P<0.01) success. CONCLUSIONS PTSMA is a promising nonsurgical technique for reduction of symptoms and LVOTG in hypertrophic obstructive cardiomyopathy. MCE has been shown to be a useful addition to probatory balloon occlusion for target vessel selection. Prospective, long-term observations of larger populations and a comparison with the established forms of therapy are necessary to determine the definitive significance of PTSMA.

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.

Sleep-disordered breathing in heart failure with normal left ventricular ejection fraction

In patients with systolic heart failure (SHF) a high prevalence of sleep‐disordered breathing (SDB) has been documented. The purpose of this study was to investigate the prevalence and type of SDB in patients with heart failure with normal left ventricular ejection fraction (HFNEF).

Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy: long term follow up of the first series of 25 patients

OBJECTIVE To determine the long term outcome in patients treated with percutaneous transluminal septal myocardial ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM). DESIGN AND SETTING Observational, single centre study. PATIENTS 25 patients (13 women, 12 men, mean (SD) age 54.7 (15.0) years) with drug treatment resistant New York Heart Association (NYHA) class 2.8 (0.6) symptoms attributed to a high left ventricular outflow gradient (LVOTG) and a coronary artery anatomy suitable for intervention. INTERVENTION PTSMA by injection of 4.1 (2.6) ml of alcohol (96%) into 1.4 (0.6) septal perforator arteries to ablate the hypertrophied interventricular septum. OUTCOME MEASURES During in-hospital follow up, enzyme rise, the frequency of atrioventricular conduction lesions requiring permanent DDD pacing, and in-hospital mortality were assessed. Long term follow up (30 (4) months, range 24–36 months) included symptoms, echocardiographic measurements of left atrial and left ventricular dimensions and function, and LVOTG. RESULTS Mean postinterventional creatine kinase rise was 780 (436) U/l. During PTSMA 13 patents developed total heart block, permanent pacing being necessary in five of them. One 86 year old patient died from ventricular fibrillation associated with intensive treatment (β mimetic and theophylline) for coexistent severe obstructive airway disease. After three months, three patients underwent re-PTSMA because of a dissatisfactory primary result, leading to LVOTG elimination in all of them. During long term follow up, LVOTG showed sustained reduction (3 (6) mm Hg at rest and 12 (19) mm Hg with provocation) associated with stable symptomatic improvement (NYHA class 1.2 (1.0)) and without significant global left ventricular dilatation. CONCLUSIONS PTSMA is an effective non-surgical technique for reduction of symptoms and LVOTG in HOCM. Prospective, long term observations of larger populations are necessary in order to determine the definitive significance of the procedure.

Influence of cardiac resynchronisation therapy on different types of sleep disordered breathing

This study investigates the influence of cardiac resynchronisation therapy (CRT) on sleep disordered breathing (SDB) in patients with severe heart failure (HF).

Adaptive servoventilation in diastolic heart failure and Cheyne-Stokes respiration.

A high prevalence of nocturnal Cheyne–Stokes respiration (CSR) has been documented in patients with heart failure with normal left ventricular ejection fraction (HFNEF). The aim of the present study was to investigate the effects of adaptive servoventilation (ASV) for treatment of CSR in these patients. In 60 patients with HFNEF, defined according to current European Society of Cardiology guidelines, CSR was documented by polysomnography (apnoea/hypopnoea index (AHI) of >15 events·h−1). ASV treatment was offered to all patients; 21 initially rejected treatment, withdrew from treatment or presented noncompliant during follow-up (controls), whereas ongoing ASV therapy was initiated in 39 patients (ASV group). Echocardiography, cardiopulmonary exercise testing and measurement of N-terminal-pro-brain natriuretic peptide were performed at baseline and follow-up (11.6±3 months). ASV therapy led to a significant reduction in AHI, longest apnoea and hypopnoea length, maximum and mean oxygen desaturation by pulse oximetry, percentage of study time with an oxygen saturation of <90% and arousal index. In addition, significant positive effects could be confirmed on absolute and predicted peak oxygen consumption, oxygen consumption at the individual aerobic–anaerobic threshold, oxygen pulse, as well as left atrial size, and transmitral flow patterns (mean early diastolic lengthening velocity and the ratio of peak early Doppler mitral inflow velocity to this lengthening velocity). ASV effectively attenuates CSR in patients with HFNEF and improves heart failure symptoms and cardiac function. Whether or not this is accompanied by an improved prognosis remains to be determined.

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.

Two-dimensional strain and strain rate imaging of the right ventricle in adult patients before and after percutaneous closure of atrial septal defects

AIMS Echocardiographic speckle tracking or two-dimensional (2D) strain analysis is a new tool to assess myocardial function. This prospective controlled study evaluates systolic right ventricular (RV) function by 2D strain in adult patients with atrial septal defect (ASD) before and 3 months after percutaneous closure. METHODS AND RESULTS Assessment of global longitudinal strain (GLS), global longitudinal strain rate (GLSR), and regional peak systolic strain (PSS) of right ventricle was performed in 33 ASD patients. The data were compared with those from 34 age-matched adults with patent foramen ovale. Before percutaneous closure, mean GLS was significantly increased in comparison to control group, and significantly reduced after closure. Analysis of regional PSS showed significant decrease in the lateral apical, lateral mid, and septal apical segments. GLSR was not influenced by ASD closure. CONCLUSION Two-dimensional strain appears to be helpful also for the assessment of RV function and its response to correction of volume overload.

Alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: low incidence of sudden cardiac death and reduced risk profile

Background The infarction induced by alcohol septal ablation (ASA) may predispose to arrhythmia and sudden cardiac death (SCD). Objective To assess survival, incidence of SCD after ASA and effects of ASA on the traditional risk factors (RFs) for SCD. Design An observational cohort-study (follow-up 8.4±4 years). Setting A dual-centre cohort. Patients 470 consecutive patients (age 56±14 years) with obstructive hypertrophic cardiomyopathy (HCM) (1996–2010). Interventions Clinically applied echo-contrast-guided ASA treatments. Main outcome measures All-cause mortality, SCD and RFs for SCD before and after ASA. Results The 10-year survival was 88% (annual all-cause death rate 1.2%) after ASA compared with 84% (p=0.06) in a matched background population. The 10-year survival free of SCD was 95% (annual SCD rate 0.5%). ASA reduced the prevalence of abnormal blood pressure response (from 23% to 9%, p<0.001), syncope (26% to 2%, p<0.001), non-sustained ventricular tachycardia (NSVT) (23% to 17%, p<0.05) and maximal wall thickness ≥30 mm (7% to 2%, p<0.001). There was a family history of SCD in 19% of the patients. The proportion of patients at high risk—that is, two or more RFs (n=89), was reduced from 25% to 8% (p<0.001). A RF score ≥2 before ASA was not associated with SCD (n=361, p=0.31). Conclusions Survival in ASA-treated patients was similar to that in the background population. The number of RFs, including the prevalence of NSVT, was markedly reduced by ASA and the incidence of SCD was correspondingly low. Thus, clinically applied ASA was safe.