Marcus Wiemer

Pulmonary capillary wedge pressure and pulmonary arterial pressure in heart failure patients with sleep-disordered breathing.

BACKGROUNDnThere is a high prevalence of central sleep apnea (CSA) in patients with chronic heart failure (CHF). The present study investigates the hypotheses that CSA in CHF patients reflects heart failure severity as measured by cardiac index (CI), pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP).nnnMETHODSnIn 105 patients with stable CHF (NYHAII, LV-EF40%) cardiorespiratory polygraphy and simultaneous right and left heart catheterization was performed.nnnRESULTSnCSA was present in 58% and obstructive sleep apnea (OSA) in 23% of patients. In CSA patients, PAP and PCWP were significantly higher when compared to patients without SDB. In CSA patients, but not in OSA patients, PCWP showed a significant correlation with apnea-hypopnea index (AHI; r=0.41, p=0.005), apnea index (AI; r=0.44, p=0.003) and central AI (cAI; r=0.358, p=0.015). Cardiac index was more impaired in CSA (1.93+/-0.5 l/min/m(2)) than in OSA patients (2.55+/-1.0 l/min/m(2)) or those without SDB (2.22+/-0.4 l/min/m(2)). A negative correlation of CI and cAI (r=-0.344, p=0.008), AI (r=-0.31, p=0.02) and AHI (r=-0.21, p<0.05) was documented exclusively in CSA patients.nnnCONCLUSIONnThe present study supports the hypotheses that the occurrence and severity of CSA in CHF patients reflects heart failure severity.

Scanning electron microscopic analysis of different drug eluting stents after failed implantation: From nearly undamaged to major damaged polymers†

Background: Implantation of drug eluting stents (DES) in tortuous and/or calcified vessels is much more demanding compared with implantation of bare metal stents (BMS) due to their larger diameters. It is unknown whether drug eluting stent coatings get damaged while crossing these lesions. Methods: In 42 patients (34 male, 68.1 ± 10 years) with 45 calcified lesions (15.9 mm ± 7.9 mm), DES could not be implanted, even after predilatation. Diabetes was present in 19 patients (45 %). Sixty‐one stents were used; 19 Cypher select™, 18 Taxus Liberté™, 10 CoStar™, 5 Endeavor RX™, 4 Xience V™. 3 Janus Carbostent™, 1 Yukon Choice S™, and 1 Axxion™ DES. The entire accessible surface area of these stents, in either the unexpanded and expanded state, were examined with an environmental scanning electron microscope (XL30 ESEM, Philips) to evaluate polymer or surface damage. Results: The polymers of Taxus Liberte, Cypher Select, Xience V, CoStar, and Janus DES were only slightly damaged (less than 3% of surface area), whereas the Endeavor RX Stents showed up to 20% damaged surface area. In DES without a polymer (Yukon and Axxion), it could be shown that most of the stent surface (up to 40%) were without any layer of drug. Conclusion: Placement of drug eluting stents in tortuous vessels and/or calcified lesions could cause major surface damage by scratching and scraping of the polymer or drug by the arterial wall, even before implantation. There were remarkable differences among the stents examined, only minor damage with the Cypher, Taxus Costar, Janus, and Xience V, whereas the Endeavor, the Yukon, and the Janus DES showed large areas of surface injury.

First-In-Man Experience With a New 7F Vascular Closure Device (EXOSEAL™): The 7F ECLIPSE Study

OBJECTIVEnThis feasibility study examined safety and effectiveness of the new EXOSEAL™ Vascular Closure Device (VCD) designed to promote hemostasis and early ambulation after percutaneous procedures.nnnBACKGROUNDnMost VCDs currently approved by the United States FDA have been associated with significantly shorter time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to standard manual or mechanical compression, but their ease of use, patient comfort during deployment, and safety profiles are variable.nnnMETHODSnPatients underwent diagnostic or interventional procedures using 7F introducer sheaths. Primary safety endpoint was the 30-day combined rate of access-related complications and primary effectiveness endpoints were TTH and TTA.nnnRESULTSnSixty patients were enrolled prospectively (mean age 63.3 ± 11.3 year, 17% diabetics). Device and procedural success was achieved in 92% and 93%, respectively. Mean TTH and TTA was 3.2 ± 3.0 minutes and 3.0 ± 6.2 hours, respectively. No deaths or serious access-related adverse events occurred. A ≥6 cm access-site hematoma was the only adverse event, observed in 3 patients.nnnCONCLUSIONSnUse of the 7F EXOSEAL™ VCD was associated with short TTH and TTA, as well as low rates of procedural and 30-day access-related complications.

Balloon Expandable Sheath for Transfemoral Aortic Valve Implantation: A Viable Option for Patients with Challenging Access

BACKGROUND AND OBJECTIVESnTranscatheter aortic valve replacement (TAVR) via femoral access is a new option for patients with severe aortic valve stenosis considered to be at high risk for conventional open-heart surgery. This procedure requires peripheral arteries that are able to accommodate the large sheaths required for valve delivery. We present a series of patients with suboptimal vascular conditions, who received a self-expandable vascular sheath.nnnMETHODS AND RESULTSnFrom January 2009 to September 2011, a total of 96 patients (43% male) were treated with the 18F Medtronic CoreValve (Medtronic, Minneapolis, MN, USA). The patients average age was 82.5u2009±u20094.6 years, and the mean EuroSCORE was 29%. In eight cases, vascular conditions were inadequate either due to advanced atherosclerotic disease (nu2009=u20095, 62.5%), or an arterial diameter ≤7u2009mm (nu2009=u20093, 37.5%). Instead of the standard 18F sheath, a balloon-expandable transfemoral introducer (SoloPath Introducer, Onset Medical Corporation, Irvine, CA, USA) was delivered and removed without complications in all but one (87.5%) patient. In the last case, rupture of the right femoral artery occurred after removal of the sheath with the need of vascular surgery.nnnCONCLUSIONnThe SoloPath sheath is a feasible alternative to conventional sheaths for transfemoral TAVR patients with difficult femoral vascular access.

Pericardial Effusion With Beginning Cardiac Tamponade Caused by a Spontaneous Coronary Artery Rupture

A 65-year-old man was admitted to his local hospital with troponin-positive acute coronary syndrome. The patient developed signs of acute heart failure and was immediately transferred to our center.nnEchocardiography demonstrated a pericardial mass (8×5 cm) with compression of the right atrium (Figure 1 and online-only Data Supplement Movie I) and a reduced contractility of the posterior left ventricular wall. Magnetic resonance imaging demonstrated a pericardial hematoma that was incompressible, not vascularized, and impinging on the right atrium (Figure 2 and online-only Data Supplement Movie II). nnnnFigure 1. Echocardiographic 4-chamber view with …

Echocardiography-Guided Percutaneous Aspiration of a Large Pericardial Cyst

A 42-year-old man was admitted with exertional breathlessness (New York Heart Association class II) and atypical chest pain. These symptoms were caused by a growing pericardial cyst situated in the left cardiophrenic angle, which had been diagnosed by chest radiography 17 years earlier (Figure 1A). Transthoracic echocardiography confirmed the presence of a large fluid-filled cyst within the pericardial space and excluded any compression of the left ventricular free wall by the cyst (Figure 2). Magnetic resonance imaging revealed …

The paclitaxel-eluting coroflex stent study II (PECOPS II) acute and 6-month clinical and angiographic follow-up, 1-year clinical follow-up.

BACKGROUND AND OBJECTIVESnPaclitaxel-coated stents have proven their efficacy for reducing restenosis in de novo coronary artery lesions and in-stent restenoses with superiority compared to bare metal stents. This study was performed to evaluate the procedural and 1 year results of the Paclitaxel-eluting Coroflex Please stent in coronary artery lesions.nnnMETHODSnOne-hundred and twenty-nine patients (66.2 +/- 8.2 years, 31.0% diabetics, 20.2% unstable angina, 41.8% multivessel disease) were enrolled per protocol for elective single stent deployment into native de novo or post-PTCA restenotic coronary lesions.The mean reference diameter was 2.84 +/- 0.43 mm, the lesion length 12.51 +/- 4.6 mm, and the minimal lumen diameter 0.75 +/- 0.29 mm. Follow-up was performed clinically in 129/129 (100%) after 6 and 12 months and angiographically in 120/129 (93%) patients after 6 months.nnnRESULTSnThe success rates of the procedure and deployment were 100% and 95.3%, respectively. The in-stent late loss and the late-loss index were 0.27 +/- 0.59 mm and 0.17 +/- 0.40 resulting in binary in-stent restenoses in 16/120 (13.3%) subjects and in-segment restenoses in 20/120 (16.7%) subjects. Major adverse cardiac events occurred in 23/129 (17.8%) during the first 6 months of follow-up with 3/129 (2.3%) myocardial infarctions, 1/129 (0.8%) secondary to stent thrombosis. From 6 to 12 months, 2/129 (1.6%) nonlesion related PCI were performed.nnnCONCLUSIONnThe data of the Paclitaxel-eluting Coroflex Please stent evaluated in PECOPS II are within the range of the other currently available Paclitaxel-eluting stent.

Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract

We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for renal cell carcinoma. Magnetic resonance imaging demonstrated a 5 x 3 cm homogeneous intracardial mass causing right ventricular outflow tract obstruction, not accessible to surgical resection. Serial echo-guided, percutaneous coil embolization of the cardial metastasis was performed with Contour SE Microparticles (150-250 or 300-500 microm) after identification of the target region of the metastasis by contrast injection (Levovist) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis, corresponding to the technique which has been described for septal ablation in hypertrophic obstructive cardiomyopathy. Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I-II) which lasted during the 19 month of survival after the index procedure.

Uncommon intraventricular thrombus formation between the posterior mitral leaflet and the lateral left ventricular wall

Transthoracic echocardiography demonstrated an intraventricular mass between the posterior mitral leaflet and the lateral left ventricular (LV) free wall in a 61-year-old man. Because of this uncommon localization an intracardial tumor, an endocarditis of the mitral valve or an intraventricular thrombus was suspected. Magnetic resonance imaging (MRI) ruled out an intracardial tumor and revealed a myocardial scarring of the LV free wall covered by an intraventricular thrombus by late gadolinium enhancement. MRI can distinguish subacute clots-which do not enhance after contrast material injection-from organized thrombi. The characterization of thrombi can be used to predict the risk of embolism, which is higher for subacute clots than for organized thrombi.

Major Polymer Damage of Drug-Eluting Stents

A 67-year-old man presented with stable angina pectoris on exertion. He had a history of type 2 diabetes, severe peripheral vascular disease with bilateral above-knee amputations, renal insufficiency requiring dialysis, and arterial hypertension for more than 20 years.nnCoronary angiography revealed a long, calcified 90% bifurcation lesion of the left anterior …