Reinhard Höltgen

A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty.

OBJECTIVES The aim of the study was to evaluate the safety, feasibility, and procedural variables by the transradial approach compared with the transfemoral access in a standard population of patients undergoing coronary catheterization. BACKGROUND Coronary catheterization is usually performed via the transfemoral approach. Transradial access may offer some advantages in comparison with transfemoral access especially under conditions of aggressive anticoagulation and antiplatelet treatment. METHODS Between July 2006 and January 2008, a total of 1,024 patients undergoing coronary catheterization were randomly assigned to the transradial or transfemoral approach. Patients with an abnormal Allens test, history of coronary artery bypass surgery, simultaneous right heart catheterization, chronic renal insufficiency, or known difficulties with the radial or femoral access were excluded. RESULTS Successful catheterization was achieved in 494 of 512 patients (96.5%) in the transradial and in 511 of 512 patients (99.8%) in the transfemoral group (p < 0.0001). Median procedural duration (37.0 min, interquartile range [IQR] 19.6 to 49.1 min vs. 40.2 min, IQR 24.3 to 50.8 min; p = 0.046) and median dose area product (38.2 Gycm(2), IQR 20.4 to 48.5 Gycm(2) vs. 41.9 Gycm(2), IQR 22.6 to 52.2 Gycm(2); p = 0.034) were significantly lower in the transfemoral group compared with the transradial access group. A median amount of contrast agent was similar among both groups. Vascular access site complications were higher in the transfemoral group (3.71%) than in the transradial group (0.58%; p = 0.0008) CONCLUSIONS The findings of the present study show that transradial coronary angiography and angioplasty are safe, feasible, and effective with similar results to those of the transfemoral approach. However, procedural duration and radiation exposure are higher using the transradial access. In contrast to the transfemoral route, the rate of major vascular complications was negligible using the transradial approach.

Electrophysiological Studies in Patients with Pulmonary Hypertension: A Retrospective Investigation

Few studies have investigated patients with pulmonary hypertension and arrhythmias. Data on electrophysiological studies in these patients are rare. In a retrospective dual-centre design, we analysed data from patients with indications for electrophysiological study. Fifty-five patients with pulmonary hypertension were included (Dana Point Classification: group 1: 14, group 2: 23, group 3: 4, group 4: 8, group 5: 2, and 4 patients with exercised-induced pulmonary hypertension). Clinical data, 6-minute walk distance, laboratory values, and echocardiography were collected/performed. Nonsustained ventricular tachycardia was the most frequent indication (n = 15) for an electrophysiological study, followed by atrial flutter (n = 14). In summary 36 ablations were performed and 25 of them were successful (atrial flutter 12 of 14 and atrioventricular nodal reentrant tachycardia 4 of 4). Fluoroscopy time was 16 ± 14.4 minutes. Electrophysiological studies in patients with pulmonary hypertension are feasible and safe. Ablation procedures are as effective in these patients as in non-PAH patients with atrial flutter and atrioventricular nodal reentrant tachycardia and should be performed likewise. The prognostic relevance of ventricular stimulations and inducible ventricular tachycardias in these patients is still unclear and requires further investigation.

Kapselendoskopie bei Patienten mit Herzschrittmachern und implantierbaren Cardioverter-Defibrillatoren – Ist die formale Kontraindikation noch gerechtfertigt?

BACKGROUND AND AIMS Capsule endoscopy is an established tool for investigation of the small intestine. Because of limited clinical experience in patients with cardiac devices the US Food and Drug Administration and the manufacturers recommend not to use capsule endoscopy in these patients. METHODS Studies investigating possible interference between small bowel capsule endoscopy and cardiac pacemakers and implanted cardioverters were analysed. For the review we considered studies published in English or German and indexed in PubMed (Medline) as well as relevant abstracts and technical data from the manufacturer. RESULTS In vitro and in vivo studies applying real capsules revealed no clinically relevant interference with pacemakers and implanted cardioverters. This evidence already has had an impact on clinical practice and recommendations of scientific societies. On the other hand wireless telemetry can interfere with CE video. CONCLUSION According to present evidence, small bowel capsule endoscopy can be used in patients with pacemakers and implanted cardioverters after obtaining informed consent concerning the formal existence of contraindication.

Konventionelles und elektroanatomisches Mapping – zentrales diagnostisches Werkzeug als Grundlage ablativer Therapieverfahren bei komplexen atrialen und ventrikulären Arrhythmien

Zunächst beschränkte sich das Spektrum zur Prävention und Therapie klinischer Tachyarrhythmien lange Zeit auf die Pharmakotherapie in Form frequenzbegrenzender oder spezifisch wirkender Antiarrhythmika. Ein Spezifikum dieser Strategie bestand und besteht in dem Umstand, dass dieser Ansatz keine kausale Therapieform, sondern lediglich Arrhythmiesuppression bewirkt. Die problematischen Konsequenzen reichen von potentiell eingeschränkter Verträglichkeit durch unerwünschte Wirkungen, reduzierter Compliance bis hin zur Tachyphylaxie. Wenn auch zunächst keine spezifischen Therapieansätze zur Verfügung standen, wuchs durch intensive anatomische und physiologische Studien des Herzens und der Elektrokardiographie bereits sehr früh das Verständnis normaler und krankhafter elektrischer Abläufe am Herzen. In den Anfängen bezog sich dieses Verständnis vornehmlich auf die elektroanatomischen Grundlagen der spezifischenReizbildungund-leitung.DieZusammenhänge zur Impulsbildung und -weitergabe durch das beteiligte Myokard wurde anhand der elektrokardiographischen Beobachtungen und deren Korrelat zu anatomischen Gegebenheiten interpretiert. So gelang vergleichsweise früh eine sehr präzise Beschreibung der putativen elektrischen Abläufe im rechten Atrium unter Vorhofflattern [1, 2]. Durch korrekte Interpretation der für die Impulsausbreitung funktionellen Bedeutung anatomischer Strukturen wie derCrista terminalis, desKoronarvenensinusostiums und des Trikuspidalklappenanulus konnten entsprechende Abläufe in anatomisch komplexen Situs bereits früh beschrieben werden. Die technische Innovation der AblationstherapiestellteinenMeilensteininder Geschichte der Rhythmologie dar. Erstmalig eröffnete sich dieMöglichkeit,mittels steuerbarer Katheter kardiale Strukturen zu modulieren bzw. zu eliminieren und so kardiale elektrische Leitungen präzise zu analysieren und im Bedarfsfall zuunterbinden.Die technischen Optionen dazu entwickelten sich rasch, und so stehen zunehmend spezifischere Ablationskatheter zur Applikation unterschiedlicher, für verschiedene Zwecke konzipierter Energieformen zur Verfügung.