Petra Maagh

Clinical and Subclinical Femoral Vascular Complications after Deployment of two Different Vascular Closure Devices or Manual Compression in the Setting of Coronary Intervention

Background: In the past two decades vascular closure devices (VCD) have been increasingly utilized as an alternative to manual compression after percutaneous femoral artery access. However, there is a lack of data confirming a significant reduction of vascular complication in a routine interventional setting. Systematic assessment of puncture sites with ultrasound was hardly performed. Methods: 620 consecutive patients undergoing elective or urgent percutaneous coronary intervention were randomly allocated to either Angioseal (AS; n = 210), or Starclose (SC; n = 196) or manual compression (MC; n = 214). As an adjunct to clinical evaluation vascular ultrasonography was used to assess the safety of each hemostatic method in terms of major and minor vascular complications. The efficacy of VCDs was assessed by achievement of puncture site hemostasis. Results: No major complications needing transfusion or vascular surgery were observed. Furthermore, the overall incidence of clinical and subclinical minor complications was similar among the three groups. There was no differences in the occurrence of pseudoaneurysmata (AS = 10; SC = 6; MC = 10), arteriovenous fistula (AS = 1; SC = 4; MC = 2) and large hematoma (AS = 11; SC = 10; MC = 14). The choice of access site treatment had no impact in the duration of hospital stay (AS = 6.7; SC = 7.4; MS = 6.4 days). Conclusions: In the setting of routine coronary intervention AS and SC provide a similar efficacy and safety as manual compression. Subclinical vascular injuries are rare and not related to VCD use.

Transradial versus transfemoral approach in coronary angiography: a matched pair analysis of cath lab equipment costs.

Introduction There is an ongoing struggle to understand the potential economic benefits that radial access may offer. Cost savings are thought to primarily occur after the procedure. The aim of our study was to analyze cath lab expenses resulting from transradial (TRA) and transfemoral approaches (TFA). Methods A total of n = 1890 matched pairs of patients were analyzed. A traditional Judkins catheter strategy was pursued for coronary angiography. Three large databases were merged to collect and compare procedural data as material, medication costs and fluoroscopy time. Results Compared to TFA diagnostic catheterization from TRA was associated with significantly lower procedural costs (€181.0 versus €167.5; p<0.001). Extra costs in TFA were primarily produced by frequent use of vascular closure devices (VCDs) in 86% of patients. However, the potential saving amount related to VCD use was only partly realized due to the higher number of extra catheters (0.53 ± 0.9 versus 0.23 ± 0.6; p<0.001) and hydrophilic guidewires (0.088 ± 0.3 versus 0.014 ± 0.1; p<0.001) used in TRA. Weak correlations were observed between the total number of cases and fluoroscopy time (r = −0.13; p<0.001) as well as material costs (r = 0.31; p<0.001). Conclusions Significant cost savings can be realized by TRA at the procedural level even when adhering to a conventional Judkins catheter strategy. Hydrophilic guidewires and additional catheters are the main cost drivers in TRA. In contrast to fluoroscopy time material costs steadily increase during the early stage of the TRA learning curve.

Impact of Cryoballoon Ablation in Hypertrophic Cardiomyopathy-related Heart Failure due to Paroxysmal Atrial Fibrillation. A Comparative Case Series.

Background: Atrial fibrillation (AF) represents a turning point in hypertrophic cardiomyopathy (HCM). Pulmonary Vein Isolation (PVI) with Radiofrequency Catheter Ablation (RFCA) is accepted to be successful in restoring sinus rhythm (SR) in HCM patients. The efficacy of cryoballoon (CB) therapy in HCM patients has not been studied so far. Methods: 166 patients with AF underwent PVI with CB technology in our single center between 1/2012 and 12/2015. To evaluate the efficacy of the CB therapy in HCM patients, we compared their clinical outcome with those in “Non-HCM” AF patients in a 3 and 6 months follow-up. Results: Out of 166 AF patients (65.7% paroxysmal AF, PAF), 4 patients had HCM and PAF (young males < 50 years). During the blanking period, 26 patients (15.8%) suffered from AF recurrence (11.0% PAF), including all HCM patients. The 6 months follow up of “Non-HCM” AF patients showed acceptable results (80% stable SR), whereas the HCM patients remained AF. In Conclusion: Even if the CB provides advantages, the single device cannot be recommended in HCM patients because of early AF recurrences. Anyway, because of the specific hemodynamic changes in HCM patients with AF, ablation should be sought in an early state of its occurrence, then, however, preferably with RFCA.

ECG-Guided Surveillance Technique in Cryoballoon Ablation for Paroxysmal and Persistent Atrial Fibrillation: A Strategy to Prevent From Phrenic Nerve Palsy

Aims: Phrenic nerve palsy (PNP) is still a cause for concern in Cryoballoon ablation (CBA) procedures. New surveillance techniques, such as invasive registration of the compound motor action potential (CMAP), have been thought to prevent the occurrence of PNP. The present study investigates the impact of CMAP surveillance via an alternative and non-invasive ECG-conduction technique during CBA. Methods: PVI with CBA was performed in 166 patients suffering from AF. Diaphragmal contraction was monitored by abdominal hands-on observation in Observation Group I; Observation Group II was treated using additional ECG-conduction, as a means of modified CMAP surveillance method. During the ablation of the right superior and inferior pulmonary veins, the upper extremities lead I was newly adjusted between the inferior sternum and the right chest, thereby recording the maximum CMAP. The CMAP in the above-mentioned ECG leads was continuously observed in a semi-quantitative manner. Results: PNP was observed in 10 (6%) patients in total. In Observation Group I, 6 out of 61 (9.8%) demonstrated PNP. In Observation Group II a significant decrease of PNP could be demonstrated (p <0,001) and occurred in 4 out of 105 patients (3.8%). While three patients from Observation Group I left the EP lap with an ongoing PNP, none of the patients in Observation Group II had persistent PNP outside of the EP lab. Conclusion: The present study demonstrates that additional ECG-conduction, used as modified CMAP surveillance, is an easy, effective and helpful additional safety measure to prevent PNP in CBA.

Herzinsuffizienz bei niedrigem BNP-Wert: Paradoxon oder Wegweiser?

HISTORY AND CLINICIAL FINDINGS  We elaborate a case of a 48-year old patient of indian descent who presented with shortness of breath, lower extremity edema and ascites in our emergency unit.One year beforehand tuberculous pleuritis was diagnosed and treated in accordance with guidelines. INVESTIGATIONS  CT-Scan of the heart revealed a pericardial thickening with calcifications. Echocardiographic examination and invasive pressure measurement did not provide any clear evidence of pericarditis constrictiva. Coronary artery disease was ruled out. In laboratory tests, the BNP-level was noticeably low despite severe cardiac decompensation. DIAGNOSIS  Due to a typically low BNP-level, pericarditis constrictiva was our suspected diagnosis TREATMENT AND COURSE:  After an intraoperative diagnosis confirmation by our cardiosurgery colleagues, a complete pericardiectomy was performed. In the follow up, the patient presented symptom-free and with normal capacity. CONCLUSION  In case of incongruent findings, the BNP-level seems to be a useful additional diagnostic tool in the diagnosis of pericarditis constrictiva.

Pulmonary vein potential mapping in atrial fibrillation with high density and standard spiral (lasso) catheters: A comparative study

The dominant single‐shot procedure for Pulmonary Vein Isolation (PVI) is the Cryoballoon Ablation (CBA) technique using a spiral catheter (Achieve™, AC) for mapping and monitoring purposes. We hypothesized that Basket Catheters, such as the High Density Mesh Mapper (HDMM), with its high‐density mapping properties, could detect Pulmonary Vein Potentials (PVPs) that the octapolar AC would not be able to identify.