Marius Schwerg

Complete Atrioventricular Block after TAVI: When Is Pacemaker Implantation Safe?

Atrioventricular (AV) block is a frequent complication of transcatheter aortic valve implantation (TAVI). TAVI is routinely performed under anticoagulation using heparin, which potentially may lead to an increased bleeding rate in patients who undergo permanent pacemaker (PPM) implantation immediately after TAVI. As the number of TAVI procedures continues to rise, data on the optimal management of TAVI‐related AV block are needed. Therefore, the aim of our study was to analyze PPM implantation‐related complications after TAVI.

Renal sympathetic denervation: early impact on ambulatory resistant hypertension.

Although guidelines recommend ambulatory blood pressure (BP) monitoring (ABPM), few data are available regarding the effects of renal denervation (RDN) on 24‐hour ABPM values. A total of 44 patients with mean systolic BP ≥135 mm Hg on ABPM despite adequate therapy were included. Basal systolic BP (SBP) and diastolic BP (DBP) were 154±11 mm Hg and 86±12 mm Hg, respectively. At 1 month, SBP and DBP were reduced to 146±18 mm Hg (P=.01) and 82±14 mm Hg and showed no further decrease up to 6 months. Only 55% of the patients responded to RDN (≥−5 mm Hg SBP), with a mean responder rate drop of 21/11 mm Hg. Neither the number of ablation points nor the amount of impedance drop was predictive of response. Only approximately half of patients with resistant hypertension responded to RDN. However, in these responders, a remarkable reduction of 24‐hour BP occurred as early as 1 month after RDN.

Therapy of Cardiac Device Pocket Infections with Vacuum-Assisted Wound Closure—Long-Term Follow-Up

Background:  Cardiac device infections are serious complications that require aggressive treatment strategies, including interventional or surgical lead extraction.

Clinical, anatomical, and technical risk factors for postoperative pacemaker or defibrillator lead perforation with particular focus on myocardial thickness.

Postoperative lead perforation is a life‐threatening complication of cardiac pacing. Identification of precipitating factors for this serious complication may help to anticipate a specific risk profile and to minimize the incidence.

Copeptin, resistant hypertension and renal sympathetic denervation

Abstract Background: Renal denervation is used as a treatment option for patients with resistant hypertension. But only a subgroup of patients benefits from renal sympathetic denervation (RDN). Biomarkers might be helpful to identify patients who respond to RDN. Copeptin as a surrogate for vasopressin levels is increased in hypertension and other cardiovascular diseases. This study aims to evaluate the effect of RDN on Copeptin and its prognostic value for response to RDN. Method and results: A total of 40 patients have been included in the study. The responder rate was 47.5% on 24 h ambulatory blood pressure measurements. The mean systolic 24 h blood pressure dropped from 152 ± 10 mmHg to 147 ± 17 mmHg (p = .044) in the six month follow up. The mean baseline level of Copeptin was 7.4 pmol/l (interquartile range 3.7–11.6) for responders and 8.4 pmol/l (interquartile range 5.7–11–8) for non-responders (p = .53). The Copeptin levels did not change over time after renal denervation. Conclusion: Baseline measurements of Copeptin in patients undergoing RDN for resistant hypertension have no predictive value for response to RDN. Despite lowering the blood pressure RDN has no influence on Copeptin levels in this short time follow up period.

Biomarker response and therapy prediction in renal denervation therapy - the role of MR-proadrenomedullin in a multicenter approach.

Abstract Background: Renal denervation has been proposed as a therapeutic option in patients with resistant hypertension. Circulating blood borne biomarkers might be helpful to identify individuals responding to RDN therapy. MR-proADM is a strong prognostic marker in patients with cardiovascular disease. The aim of this multicenter study was to evaluate the effect of RDN on MR-proADM concentrations. Methods and results: We measured MR-proADM, BNP, and MR-proANP in 110 patients before and after RDN in a multicenter setting. All patients were followed up after 1 and 6 months by office and ambulatory blood pressure (BP) measurements. The mean office BP decreased from 165/89 to 152/87 mmHg 6 months after RDN (systolic: p < 0.001; diastolic: ns), the responder-rate was 74%. Intriguingly MR-proADM concentrations increased from 0.66 to 0.69 nmol/L (p < 0.001) and were significantly associated with reduction of systolic office BP after 6 months in multivariate analyses (coefficient −0.0018, p < 0.001). In therapy-responders MR-proADM concentrations showed a significantly higher increase over time (coefficient 0.0105, p < 0.05), as compared to non-responders. There were no significant differences in BP change for individuals with low and high baseline MR-proADM (BP-Delta low MR-proADM −23/−4 mmHg vs. high MR-proADM −24/−5 mmHg). The natriuretic biomarkers BNP and MR-proANP did not change significantly after 6 months. Biomarkers at baseline were not able to predict for therapy-responder. Conclusion: In patients undergoing RDN, baseline measurements of various biomarkers had no prognostic use for therapy success in this short time follow-up period in a multicenter approach. Intriguingly, MR-proADM showed a significant association with BP reduction after 6 months.

Prevalence of E/A Wave Fusion and A Wave Truncation in DDD Pacemaker Patients with Complete AV Block under Nominal AV Intervals

AIMS Optimization of the AV-interval (AVI) in DDD pacemakers improves cardiac hemodynamics and reduces pacemaker syndromes. Manual optimization is typically not performed in clinical routine. In the present study we analyze the prevalence of E/A wave fusion and A wave truncation under resting conditions in 160 patients with complete AV block (AVB) under the pre-programmed AVI. We manually optimized sub-optimal AVI. METHODS We analyzed 160 pacemaker patients with complete AVB, both in sinus rhythm (AV-sense; n = 129) and under atrial pacing (AV-pace; n = 31). Using Doppler analyses of the transmitral inflow we classified the nominal AVI as: a) normal, b) too long (E/A wave fusion) or c) too short (A wave truncation). In patients with a sub-optimal AVI, we performed manual optimization according to the recommendations of the American Society of Echocardiography. RESULTS All AVB patients with atrial pacing exhibited a normal transmitral inflow under the nominal AV-pace intervals (100%). In contrast, 25 AVB patients in sinus rhythm showed E/A wave fusion under the pre-programmed AV-sense intervals (19.4%; 95% confidence interval (CI): 12.6-26.2%). A wave truncations were not observed in any patient. All patients with a complete E/A wave fusion achieved a normal transmitral inflow after AV-sense interval reduction (mean optimized AVI: 79.4 ± 13.6 ms). CONCLUSIONS Given the rate of 19.4% (CI 12.6-26.2%) of patients with a too long nominal AV-sense interval, automatic algorithms may prove useful in improving cardiac hemodynamics, especially in the subgroup of atrially triggered pacemaker patients with AV node diseases.

Renal Denervation Therapy: Indications and Success Factors

Arterial hypertension is a common and an increasing health care problem. In Germany and other Western countries, prevalence rates are as high as 50%. Of these, 13% of patients suffer from refractory hypertension, where the target blood pressure is not achievable with >3 antihypertensive substances. Renal denervation therapy (RDT) is a relatively new, catheterization-based intervention to treat patients with refractory hypertension. The rationale of RDT is the mechanical destruction with high frequency ablation of renal sympathetic fibers, which can be easily accessed via the renal artery. The first clinical trials evaluating effect and safety of the procedure have been promising, and RDT is being routinely used in specialized centers.

Valve in valve implantation of the CoreValve Evolut R in degenerated surgical aortic valves

BACKGROUND The new CoreValve Evolut R has an improved design to minimize paravalvular leak-age and allows repositioning of the valve. For patients with degenerated bioprosthetic aortic valves, transcatheter aortic valve implantation (TAVI) represents a less invasive option. Herein reported are valve-in-valve (ViV) implantations of this new valve. METHODS A total of 26 patients (mean age 79.4 ± 6.1 years, 17 males and 9 females) were treated for severe prosthesis stenosis (n = 9), severe regurgitation (n = 8) or severe combination of stenosis and regurgitation (n = 9). All patients underwent transthoracic echocardiography before and after ViV implantation. RESULTS Valve-in-valve implantation of a CoreValve Evolut R was performed successfully in all pa-tients. The mean transaortic gradient for stenotic valves determined by transthoracic echocardiography was reduced significantly from 37.5 ± 15.3 mmHg in patients with prosthesis stenosis to 16.3 ± 8.2 mmHg (p < 0.001). In all cases with severe prosthesis regurgitation, regurgitation was reduced to none or mild. All-cause mortality after 30 days was 0%. CONCLUSIONS It was concluded that CoreValve Evolut R is well suited for ViV implantation.