Norbert Franz

Anatomic Patterns of Renal Arterial Sympathetic Innervation: New Aspects for Renal Denervation

AIMS Initial studies of catheter-based renal arterial sympathetic denervation to lower blood pressure in resistant hypertensive patients renewed interest in the sympathetic nervous systems role in the pathogenesis of hypertension. However, the SYMPLICITY HTN-3 study failed to meet its prespecified blood pressure lowering efficacy endpoint. To date, only a limited number of studies have described the microanatomy of renal nerves, of which, only two involve humans. METHODS AND RESULTS Renal arteries were harvested from 15 cadavers from the Klinikum Osnabruck and Schuchtermann Klinik, Bad Rothenfelde. Each artery was divided longitudinally in equal thirds (proximal, middle, and distal), with each section then divided into equal superior, inferior, anterior, and posterior quadrants, which were then stained. Segments containing no renal nerves were given a score value = 0, 1-2 nerves with diameter <300 µm a score = 1; 3-4 nerves or nerve diameter 300-599 µm a score = 2, and >4 nerves or nerve diameter ≥600 µm a score = 3. A total of 22 renal arteries (9 right-sided, 13 left-sided) were suitable for examination. Overall, 691 sections of 5 mm thickness were prepared. Right renal arteries had significantly higher mean innervation grade (1.56 ± 0.85) compared to left renal arteries (1.09 ± 0.87) (P < 0.001). Medial (1.30 ± 0.59) and distal (1.39 ± 0.62) innervation was higher than the proximal (1.17 ± 0.55) segments (p < 0.001). When divided in quadrants, the anterior (1.52 ± 0.96) and superior (1.71 ± 0.89) segments were more innervated compared to posterior (0.96 ± 0.72) and inferior (0.90 ± 0.68) segments (P < 0.001). CONCLUSIONS That the right renal artery has significantly higher innervation scores than the left. The anterior and superior quadrants of the renal arteries scored higher in innervation than the posterior and inferior quadrants did. The distal third of the renal arteries are more innervated than the more proximal segments. These findings warrant further evaluation of the spatial innervation patterns of the renal artery in order to understand how it may enhance catheter-based renal arterial denervation procedural strategy and outcomes. CONDENSED ABSTRACT The SYMPLICITY HTN-3 study dealt a blow to the idea of the catheter-based renal arterial sympathetic denervation. We investigated the location and patterns of periarterial renal nerves in cadaveric human renal arteries. To quantify the density of the renal nerves we created a novel innervation score. On average the right renal arteries were significantly more densely innervated than the left renal arteries, the anterior and superior segments were significantly more innervated compared to the posterior and inferior segments, absolute innervation scores in the proximal third of the left or right renal arteries were always lower when compared to distal segments. These findings may enhance catheter-based renal arterial denervation procedural strategy and outcomes.

A Novel Method of Axillary Venipuncture Using the Cephalic Vein as a Sole Anatomic Landmark

The use of axillary venipuncture for pacemaker lead implantation has become a common technique. However, because of its relatively high complexity, it is still not the method of choice in most hospitals. As such, we propose an effective, simple, and safe technique for axillary venipuncture using only the cephalic vein as an anatomic landmark, with the possibility of selective cephalic contrast venography as a backup. A total of 108 patients were examined. After preparation of the cephalic vein, the puncture needle was inserted into the superficial pectoral muscle 1.5-2 cm medial to the cephalic vein and advanced in the direction parallel to the course of the cephalic vein. The needle was advanced up to 3-4 cm at an angle of 30° relative to the body surface, applying gentle suction during advancement. If after 3 attempts the axillary vein was not accessed, the same process was repeated 3-4 cm medial to the cephalic vein. If this was not effective, contrast venography of the axillary vein through the cephalic vein was performed. In 92.6% of all cases, the axillary vein was cannulated without fluoroscopic control, and in 7.4% of cases, fluoroscopic control and selective contrast venography were needed. A novel technique for axillary venipuncture using the cephalic vein as a single landmark is a simple, effective, and safe tool for pacemaker lead implantation. In some cases, selective cephalic contrast venography is an elegant and effective addition.

Transapical transcatheter aortic valve implantation followed by transfemoral transcatheter edge-to-edge repair of the tricuspid valve using the MitraClip system – a new treatment concept for an inoperable patient with significant aortic stenosis and severe tricuspid valve regurgitation

Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis. The benefits of both methods have been confirmed in large cohort studies [1–4]. Recently, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system was described for high surgical risk or inoperable patients [5–7].

Simultaneous transfemoral transcatheter mitral and tricuspid valve edge-to-edge repair (using MitraClip system) completed by atrial septal defect occlusion in a surgically inoperable patient. First-in-human report.

Transcatheter transfemoral mitral valve repair using the MitraClip system (Abbott Vascular, USA) is used in high-risk or inoperable patients with severe mitral regurgitation. We report the first-in-human simultaneous transfemoral clipping of the mitral and tricuspid valve completed by occlusion of an atrial septal defect (ASD). The procedure was performed in an 84-year-old patient in October 2015. After effective reduction of mitral and tricuspid regurgitations using the MitraClip system a PFO Occluder (St. Jude Medical, USA) was implanted. Transfemoral simultaneous mitral and tricuspid valve repair using the MitraClip system with ASD occlusion seems to be an effective therapy for high-risk or inoperable patients.

Transcatheter aortic valve implantation at a high-volume center: the Bad Rothenfelde experience

Introduction The “transfemoral (TF) first” approach to access route selection in transcatheter aortic valve implantation (TAVI) is popular; however, the risk of major vascular complications is substantial. The “best for TF” approach identifies only the patients with ideal anatomy for TF-TAVI, potentially minimizing complications. Aim To characterize the outcomes of patients undergoing TAVI at a large-volume site that employs this approach. Material and methods Patients who underwent TAVI at the Bad Rothenfelde Heart Centre between 2008 and 2016 were consecutively enrolled. Findings were compared to those from large, multicenter registries. Results Of the 1,644 patients enrolled, 1,140 underwent TA- and 504 TF-TAVI. Comorbidities were more frequent in TA patients, who also had higher risk scores (EuroSCORE: 25.5% vs. 21.2%; STS score: 11.0% vs. 7.5%; p < 0.001 for both). Rates of conversion to open surgery, major vascular complications and intra-procedural mortality did not differ between groups. At 30 days, mortality rates were higher in the TA group (3.9% vs. 1.9%, p = 0.036). Stroke/transient ischemic attack and permanent pacemaker implantation rates did not differ significantly between groups (2.0% and 9.1% overall, respectively). Compared to multicenter registries, trends in mortality and complication rates were similar, though magnitudes were lower in the present study. In contrast with the present study, major vascular complication rates in multicenter registries are significantly higher for TF compared to TA patients. Conclusions At this high-volume center, the use of a “best for TF” approach to TAVI resulted in low mortality and complication rates.

“All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human

Address for correspondence: Marek Kowalski MD, PhD, Department of Cardiology, Schüchtermann-Klinik, Ulmenallee 5-11, 49214 Bad Rothenfelde, Germany, phone: +49 542464130023, e-mail: MKowalski@schuechtermann-klinik.de Received: 16.10.2017, accepted: 25.11.2017. Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis [1, 2]. Furthermore, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system has recently been described for high-risk patients with tricuspid regurgitation [3]. This valvular dysfunction is mainly caused by right ventricular dilatation driven by volume or pressure overload secondary to heart failure, mitral disease and/or aortic valvular disease [4]. Thus, most of these patients suffer from multivalvular disease. However, simultaneous transapical TAVI and transfemoral clipping of the mitral as well as tricuspid valve with MitraClip completed by occlusion of an atrial septal defect has not been described so far. We report hereby this firstin-human intervention in a high-risk patient. An 81-year-old male patient with a history of biventricular heart decompensation suffered from severe dyspnea on admission (New York Heart Association functional class III), lower leg edema, pleural effusions and stage III chronic kidney disease. Echocardiography revealed severe aortic stenosis (aortic valve area = 0.7 cm2) (Fig. 1). In addition, severe regurgitation of the tricuspid valve (effective regurgitation orifice area (EROA) = 0.88 cm2) and mitral valve (EROA = 0.44 cm2) with tethered leaflets was found (Fig. 2). Left and right ventricular function were reduced (ejection fraction of 50% and 35%, respectively). Elevated systolic pulmonary artery pressure could be documented (65 mm Hg). As a result of heart team discussion the patient was declared as surgically inoperable and qualified for transapical transcatheter aortic valve implantation – not suitable for a transvascular approach – followed by transfemoral edgeto-edge repair of mitral and tricuspid valves using the MitraClip system within one simultaneous procedure. All interventions were performed on July, 4th, 2017 under general anaesthesia using twoand three-dimensional transesophageal echocardiography (TEE) (iE 33, Philips Healthcare, Netherlands) and fluoroscopy guidance (Axiom Artis Zeefloor AXH 1604, Siemens, Germany). Unfractionated heparin was administered aiming at an activated clotting time (ACT) of 250–300 s throughout the procedure. For the transapical TAVI the left ventricular apex was surgically exposed (anterolateral minithoracotomy) and the apical suture was prepared. The apex was then punctured and a guidewire was placed in the left ventricular cavity and advanced through the aortic valve into the ascending aorta. Using the guidewire, a 5 Fr Impulse Femoral Right 4 Angiographic Catheter (Boston Scientific, USA) was introduced via the ventricular cavity in the descending aorta. Next a guide wire was placed (Amplatzer Super Stiff, Boston Scientific, USA) through the apex into the descending aorta. After that the 18 Fr sheath was introduced (Certitude, Edwards, USA) followed by the crimped valve (Sapien 3 TA 26 mm Aortic Bioprosthesis, Edwards, USA) and the device was positioned in the aortic valve annulus. The valve was implanted under aortic angiographic control and rapid pacing. The apex was closed after removing the introducer system. The procedure resulted in correct positioning of the aortic bioprosthesis with minimal aortic regurgitation (Fig. 3). Echocardiography showed a mean gradient of 5 mm Hg and an aortic valve area of 3.1 cm2. Then the mitral valve edge-to-edge repair using the MitraClip system was performed. After puncture of the right femoral vein and reaching the left atrium via transseptal puncture the steerable guiding catheter was placed into the left atrium and the clip delivery system (CDS) was introduced into the guiding catheter. The next step of the maneuver consisted of advancing the MitraClip device into the left atrium, opening both arms, navigation and advancing the system into the left ventricle. By retracting the MitraClip device both leaflets of the mitral valve were grasped and closed to coapt. Doing so, an effective reduction of mitral regurgitation could be achieved and the clip was deployed. The clip delivery system was evacuated. “All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human

Transapical Angiography in a Patient With Severe Aortic Stenosis Undergoing Transapical Transcatheter Aortic Valve Implantation

Transapical transcatheter aortic valve implantation (TA-TAVI) is the method of choice in patients with severe stenosis of the aortic valve, high operative risk, and an adverse peripheral vasculature. The procedure is generally guided by peripheral arterial access angiography. We report on a 71-year-old patient in whom, because of the absence of an alternative peripheral arterial access route, TA-TAVI was supported by the apical insertion of the angiography catheter. This approach was effective and safe, and proper valve deployment was feasible without unexpected procedural complications.