Sebastian Barth

Progression From Esophageal Thermal Asymptomatic Lesion to Perforation Complicating Atrial Fibrillation Ablation: A Single-Center Registry

Background— Up to 40% of patients demonstrate endoscopically detected asymptomatic esophageal lesions (EDEL) after atrial fibrillation ablation. Methods and Results— Patients undergoing first atrial fibrillation ablation and postinterventional esophageal endoscopy were included in the study. Occurrence of esophageal perforating complications during follow-up was related to documented EDEL (category 1: erythema/erosion; category 2: ulcer). In total, 1802 patients underwent first atrial fibrillation ablation procedure between January 2013 and August 2016 at our institution. Out of this group, 832 patients (506 male patients, 61%; 64.0±10.0 years) with symptomatic paroxysmal (n=345; 42%) or persistent atrial fibrillation underwent postprocedural esophageal endoscopy. Patients were ablated using single-tip ablation with conventional or surround flow irrigation and circular ablation catheters with open irrigation (nMARQ). In 295 of 832 patients (35%), a temperature probe was used. EDEL occurred in 150 patients (18%; n=98 category 1 EDEL, n=52 category 2 EDEL). In 5 of 832 patients (0.6%), an esophageal perforation (n=3) or an esophagopericardial or atrioesophageal fistula (n=2) occurred 15 to 28 days (19±6 days) after ablation. Two patients (1 atrioesophageal fistula and 1 esophagopericardial fistula) died. Esophageal perforation occurred only in patients with category 2 lesions (absolute risk, 9.6%). In a logistic regression analysis, ulcers were identified to be a significant predictor for esophageal perforating complications. Conclusions— Postablation endoscopy seems to identify patients at high risk of esophageal perforating complications only occurring in patients with category 2 EDEL. One out of 10 postablation esophageal ulcers progressed to perforation, and no patient without esophageal thermal ulcers showed the occurrence of perforating esophageal complications.

Impact of right and left ventricular systolic dysfunction on perioperative outcome and long-term survival after transcatheter aortic valve replacement

BACKGROUND Aim of the study was to determine the impact of right- and left-ventricular systolic dysfunction on perioperative outcome and long-term survival after TAVR. METHODS Study population consisted of 702 TAVRs between 2009 and 2014, 345 by TF, 357 by TA route. RV and LV function were determined by TAPSE and LVEF measurement during baseline echocardiography. Patients were divided according to TAPSE (>18 mm/14-18 mm/<14 mm) and LVEF (>50%/30-50%/<30%) tertiles. Outcome at day-30 and Kaplan-Meier 4-year survival were analyzed. RESULTS Impaired RV and LV-function did not adversely affect mortality, stroke, bleeding, and vascular-complications at 30 days. Patients with TAPSE < 14 mm displayed elevated rate of renal failure requiring dialysis (11%; P < 0.01). Kaplan-Meier survival was adversely affected by RV-systolic dysfunction RVSD (P < 0.01). Multivariate analysis revealed that impaired RVSD but not LVSD was an independent determinant for late mortality (hazard ratio TAPSE 14-18 mm: 1.53; P = 0.02; TAPSE <14 mm: 2.12; P < 0.01). CONCLUSIONS Peri-operative mortality and risk of stroke after TAVR are not adversely affected by preexisting RV or LV dysfunction. Long-term survival is impaired in patients with RVSD. RVSD but not LVSD is an independent risk factor for late mortality. TAVR should be the preferred therapy for patients with RVSD and LVSD, especially when patient is suitable for TF.

The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry

Objectives: To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). Methods: A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed. Results: TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. Conclusions: About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.

Cardiac Computed Tomography in Certified German Chest Pain Units.

OBJECTIVE The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients. METHODS For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared. RESULTS Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21). CONCLUSIONS Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

On versus off-hour care of patients with acute coronary syndrome and persistent ST-segment elevation in certified German chest pain units.

Background: Regional healthcare projects improve the off-hour care of patients with acute coronary syndromes and persistent ST-segment elevation myocardial infarction (STEMI). To analyse differences in quality of care between on and off-hour care of STEMI patients admitted to certified German chest pain units. Methods: A total of 1107 STEMI patients from the German chest pain unit registry were enrolled. Analyses comprised critical time intervals (symptoms to first medical contact (FMC), FMC to admission, symptoms to admission, symptoms to balloon, FMC to balloon, door to balloon times) and major adverse cardiac and cerebrovascular events at follow-up. Results: 54.8% of patients were admitted off-hours. Symptoms to admission (2:28 (1:28–5:20 h) vs. 3:16 h (1:35–8:06 h), P<0.001), symptoms to FMC (1:15 h (0:33–3:00 h) vs. 2:00 h (0:40–6:46 h), P<0.001) and FMC to admission intervals (0:45 h (0:30–1:20 h) vs. 0:52 h (0:32–1:35 h), P=0.09) were shorter during off-hours. Percutaneous revascularisation rates were high and without difference between on and off-hours (95.5% vs. 96.8%, P=0.30). Door to balloon times were significantly less during on-hours (0:32 h (0:18–1:06 h) vs. 0:44 h (0:23–1:20 h), P<0.01) without negative impact on the proportion of patients with a door to balloon time of <60 min (72.6% vs. 68.4%, P=0.19), symptoms to balloon (3:49 h (2:12–10:46 h) vs. 3:30 h (2:04–7:41 h), P=0.08) or FMC to balloon times (1:26 h (0:56–2:22 h) vs. 1:30 h (1:03–2:29 h), P=0.14). Major adverse cardiac and cerebrovascular event rates did not differ significantly between on and off-hours (log-rank test P=0.36). Conclusions: The German chest pain unit network ensures rapid and structured preclinical and in-hospital care independent from the circadian variation of admission. Slower door to balloon times off-hours are compensated by faster symptoms to admission or symptoms to FMC intervals. Further efforts should focus on patient awareness programmes on-hours and STEMI alarming tracks off-hours.

Left ventricular ejection fraction of < 20%: Too bad for MitraClip©?

This study sought to investigate whether the percutaneous mitral regurgitation (MR) reduction with the MitraClip® system in end‐stage heart failure patients with a left ventricular ejection fraction (LVEF) of <20% also effects beneficial outcome or whether the underlying myogenic problem is leading and therefore of prognostic relevance.

Guideline-adherence regarding critical time intervals in the German Chest Pain Unit registry

Background: Since 2008, the German Cardiac Society certified 256 Chest Pain Units (CPUs). Little is known about adherence to recommended performance measures in patients with suspected acute coronary syndrome (ACS) presenting to CPUs. We investigated guideline-adherence regarding critical time intervals and selected performance measures in German Chest Pain Units. Methods: From 2008 to 2014, 23,804 consecutive patients with suspected ACS were prospectively enrolled in the Chest Pain Unit registry of the German Cardiac Society. Results: Median time from symptom onset to first medical contact was 2 h in patients with ST-elevation myocardial infarction (STEMI) and 4 h in patients with unstable angina and non-STEMI (NSTEMI). In patients with STEMI, median time from hospital admission to percutaneous coronary intervention (PCI) was 40 min and median time from first medical contact to PCI was 1 h 35 min. Primary PCI was performed in 94.7% of patients with STEMI, 70.0% of patients with NSTEMI and 37.4% of patients with unstable angina. PCI was performed during the first 24 h in 79.5% of patients with NSTEMI and the first 72 h in 89.0% of patients with unstable angina. Electrocardiograms were performed in 99.5% after a median of 6 min after admission and obtained within 10 min in 71%. Interestingly, 56.1% of patients were found to have non-ACS diagnoses, underlining the importance of access to additional diagnostic modalities including echocardiography, stress testing or computed tomography. Conclusions: Guideline-adherence regarding critical time intervals and primary PCI rates is good in German Chest Pain Units. More than half of patients admitted with suspected ACS had non-ACS diagnoses. Improvements in pre-hospital time delays through public awareness programmes are warranted.

Coronary CT angiography in patients with atrial fibrillation: Standard-dose and low-dose imaging with a high-resolution whole-heart CT scanner

ObjectiveTo compare image quality, observer confidence, radiation exposure in the standard-dose (SD-CCTA) and low-dose (LD-CCTA) protocols of coronary CT angiography (CCTA) in patients with atrial fibrillation (AF).Material and methodsCCTA was performed in 303 patients using a CT scanner with 16-cm coverage (111 scans during sinus rhythm (SR); 192 during AF). LD-CCTA was used in 218 patients; SD-CCTA in 85 patients suspected of having coronary artery disease (CAD). Image quality and observer confidence were evaluated on 5-point scales. Radiation doses were recorded.ResultsImage quality was superior in the SD-CCTA compared to the LD-CCTA (SR 1.45±0.40; AF 1.72±0.46; vs. SR 1.83±0.48; AF 1.92±0.50; p < 0.001). Observers were more confident with SD-CCTA than with LD-CCTA (SR 1.38±0.33; AF 1.61±0.43; vs. SR 1.70±0.45; AF 1.82±0.50; p < 0.001). Radiation doses in AF were significantly higher than in the SR (LD-CCTA, 1.68±0.71 mSv; SD-CCTA, 3.72±1.95 mSv; vs. LD-CCTA, 1.3 ±0.52 mSv; SD-CCTA, 2.67±1.47 mSv; p < 0.001).ConclusionUsing a low-dose protocol in AF, radiation exposure can be decreased by 50 % at the expense of 20 % impaired image quality. A low-dose CCTA protocol can be considered in young patients, whereas the standard-dose protocol is recommended for older patients and those suspected of having CAD.Key Points• Whole-heart CT allows visualization of the coronary arteries in atrial fibrillation.• Low-dose CT decreases radiation exposure by 50%, image quality by 20%.• Standard-dose CT seems advantageous when concomitant coronary artery disease is suspected.

Decreasing incidence of coronary heart disease in extreme obesity (BMI≥40)-A single centre experience.

AIM The aim of our comprehensive single centre analysis was to evaluate the incidence of coronary heart disease (CHD) in extremely obese patients. METHODS AND RESULTS Between 2005 and 2015 we investigated retrospectively 23,359 patients undergoing cardiac catheterisation in our institution. Patients were divided in six weight classes according to World Health Organization (WHO) criteria [1] (WHO, 2000). Cardiovascular risk factors, comorbidities, CCS stadium [2] (Cox and Naylor, 1992) and NYHA functional class [3] (The Criteria Committee of the New York Heart Association, 1994) were retrieved from electronic patient records. Using multivariable analysis the odds ratio for the target variable CHD with presence of >50% angiographic stenosis was ≥1 with regard to age (OR 1.049, 95% CI 1.045-1.052), male sex (OR 2.507, 95% CI 2.329-2.699), cardiovascular risk factors, atherosclerosis (OR 1.651, 95% CI 1.498-1.820), and presence of angina (OR 4.408, 95% CI 3.892-4.993). NYHA functional class I-IV, absence of angina (OR 0.818, 95% CI 0.729-0.918), and BMI≥40 (OR 0.592, 95% CI 0.494-0.709) resulted in an odds ratio of ≤1. Underweight patients had a higher (5.3%) and overweight (1.2%) and obese patients (class I 0.9% and II 1.1%) a slightly lower all-cause in-hospital mortality compared to extremely obese patients (1.6%). CONCLUSION Severely obese patients treated in our hospital surprisingly showed a decreased incidence of CHD (46.1% in normal weight and 38.6% in extremely obese patients) while comorbidities increased CHD as expected. Although CHD burden was lower, obesity and associated comorbidities resulted in higher all-cause-in-hospital mortality.

Influence of experience on procedure steps, safety, and functional results in edge to edge mitral valve repair—a single center study

Objectives: We sought to determine the effects of experience on the Mitraclip® procedure steps as well as procedure safety and functional results.