Sylvia Otto

Detection of irregular patterns of myocardial contraction in patients with hypertensive heart disease: a two-dimensional ultrasound speckle tracking study.

Objective To evaluate the effect of myocardial hypertrophy in patients with arterial hypertension on regional myocardial function and left ventricular twist. Methods Eighty patients with normal coronary angiograms and ejection fraction higher than 55% were divided according to left ventricular mass indexed to body height (LVMH) into a group with and without left ventricular hypertrophy (LVH). The absolute values and time-to-peak values of overall strain (S), systolic (SRS) and early diastolic strain rate (SRE) were measured in longitudinal, circumferential and radial directions using two-dimensional speckle tracking echocardiography. Left ventricular twist and twist rate curves were calculated from rotation curves obtained from apical and basal parasternal short-axis planes. Results In the patient group with LVH, SRS and SRE, quantified in longitudinal and circumferential direction, were lower compared with the group without LVH. In addition, systolic twist rate and diastolic untwist rate were significantly lower in this patient group, too. No differences between patients groups were found for peak overall S measured in any direction or left ventricular twist. LVMH correlated significantly with longitudinal SRS (r = 0.48, P < 0.001), longitudinal SRE (r = −0.48, P < 0.001), systolic twist rate (r = 0.37, P = 0.006) and diastolic untwist rate (r = −0.27, P = 0.046). Conclusion In conclusion, LVH in patients with arterial hypertension predominantly affected longitudinal and circumferential deformation rate. Moreover, LVH resulted in a significant reduction of systolic twist rate and diastolic untwist rate, whereas overall left ventricular twist angle was not influenced by LVMH.

A PROSPECTIVE RANDOMIZED STUDY USING OPTICAL COHERENCE TOMOGRAPHY TO ASSESS ENDOTHELIAL COVERAGE AND NEOINTIMAL PROLIFERATION AT 6 MONTHS AFTER IMPLANTATION OF A CORONARY EVEROLIMUS-ELUTING STENT COMPARED WITH A BARE METAL STENT POSTDILATED WITH A PACLITAXEL-ELUTING BALLOON (OCTOPUS TRIAL)

Safety concerns regarding use of drug eluting coronary stents are related to late stent thrombosis, which is facilitated by incomplete endothelial stent coverage. Optical coherence tomography (OCT) is the new gold standard for intravascular imaging, enabling precise assessment of neointimal

Stent Coverage and Neointimal Proliferation in Bare Metal Stents Postdilated With a Paclitaxel-Eluting Balloon Versus Everolimus-Eluting Stents Prospective Randomized Study Using Optical Coherence Tomography at 6-Month Follow-Up

Background—In this randomized trial, strut coverage and neointimal proliferation of a therapy of bare metal stents (BMSs) postdilated with the paclitaxel drug-eluting balloon (DEB) was compared with everolimus drug-eluting stents (DESs) at 6-month follow-up using optical coherence tomography. We hypothesized sufficient stent coverage at follow-up. Methods and Results—A total of 105 lesions in 90 patients were treated with either XIENCE V DES (n=51) or BMS postdilated with the SeQuent Please DEB (n=54). At follow-up, comparable results on the primary optical coherence tomography end point (percentage uncovered struts 5.64±9.65% in BMS+DEB versus 4.93±9.29% in DES; P=0.366) were found. Thus, BMS+DEB achieved the prespecified noninferiority margin of 5% uncovered struts versus DES (difference between treatment means, 0.71%; one-sided upper 95% confidence interval, 4.14%; noninferiority P=0.04). Optical coherence tomography analysis showed significantly more global neointimal proliferation in the BMS+DEB group (15.7±7.8 versus 11.0±5.2 mm3 proliferation volume/cm stent length; P=0.002). No significant focal in-stent stenosis analyzed with angiography (percentage diameter stenosis at follow-up, 22.8±11.9 versus 16.9±10.4; P=0.014) and optical coherence tomography (peak local area stenosis, 39.5±13.8% versus 36.8±15.6%; P=0.409) was found. Conclusions—Good stent strut coverage of >94% was found in both therapy groups. Despite greater suppression of global neointimal growth in DES, both DES and BMS+DEB effectively prevented clinically relevant focal restenosis at 6-month follow-up. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01056744.

Renal denervation with cryoenergy as second-line option is effective in the treatment of resistant hypertension in non-responders to radiofrequency ablation.

AIMS Renal denervation (RDN) with radiofrequency (RF) is being used to treat resistant hypertension (rHTN). As 15-30% of treated patients are non-responders to RDN, we investigated whether RDN with cryoenergy can serve as a second-line option. METHODS AND RESULTS Ten non-responder patients (mean age 55 years, six male) with rHTN were treated with cryoenergy for RDN. In order to qualify as non-responders, patients had to show systolic 24 hr ambulatory BP (ABP) ≥150 mmHg (median ABP 183/102 mmHg, median office- based BP [OBP] 191/108 mmHg) despite treatment with ≥4 different antihypertensive drugs (mean 6), and further not show a reduction of systolic ABP ≥10 mmHg at ≥3 months after RDN with RF. The three/six/12-month follow-up (FU) comprised clinical and biochemical evaluation, OBP and ABP measurement. Additionally, at six months, duplex sonography was performed. Cryoablation with a 7 Fr cryoablation catheter (Freezor® Xtra; Medtronic, Minneapolis, MN, USA) was performed in all patients without complications (four applications in both renal arteries, every four minutes, temperature -75°C). At three, six, and 12 months we found a reduction in systolic OBP of -41/-47/-61 mmHg (n=10/7/6; p=0.044 for all), diastolic OBP of -18/-14/-34 mmHg, systolic ABP of -38/-35/-52 mmHg (n=9/7/6, p=0.014 for all), and diastolic ABP of -20/-13/-18 mmHg (p=0.043 for all), respectively. During FU, no complications occurred and the renal function remained unchanged. CONCLUSIONS The significant reduction in systolic OBP and ABP observed qualifies RDN with cryoenergy as an effective second-line therapeutic option in non- responders to RDN with RF.

A prospective randomised study using optical coherence tomography to assess endothelial coverage and neointimal proliferation at 6-months after implantation of a coronary everolimus-eluting stent compared with a bare metal stent postdilated with a paclitaxel-eluting balloon (OCTOPUS Trial): rationale, design and methods.

BACKGROUND Safety concerns regarding use of drug-eluting stent systems (DES) are related mostly to late stent thrombosis, which is facilitated by incomplete stent endothelial coverage. Specific information about time course and amount of endothelial strut coverage of different DES is required, in order to further refine the concept of antiplatelet therapy after DES implantation. Optical coherence tomography (OCT) is emerging as a new gold standard for endovascular imaging of stents, atherosclerosis progression, vulnerable plaque, and neointimal proliferation. The aim of this study is a comparative evaluation using OCT of the XIENCE V everolimus-eluting stent (Abbot Vascular, Santa Clara, CA, USA) on one hand, and the bare metal stent Coroflex Blue postdilated with the paclitaxel-eluting balloon Sequent Please (both from B Braun Melsungen AG, Melsungen, Germany) on the other hand, with respect to endothelial coverage and neointimal proliferation. METHODS Eighty patients scheduled for elective percutaneous coronary intervention (PCI) of a native coronary stenosis suitable for DES implantation and OCT imaging are scheduled to be openly randomised 1:1 to either XIENCE or Coroflex Blue/Sequent Please. The study is conducted prospectively at a university high-volume PCI centre with OCT expertise. Angiographic follow-up and time-domain OCT imaging with motorised pull-back at 1 mm/s are planned six months after study stent implantation in all patients. OCT endpoints are: (1) endothelial coverage, expressed as % of struts without coverage and % of stent length containing non-covered struts, and respectively (2) neointimal proliferation, given as % neointimal volumetric proliferation within the whole stent and also as peak focal % neointimal area proliferation. The study is not powered for clinical endpoints, which are: subacute or late stent thrombosis and need for revascularisation of the stent segment. Given the high number of measurements (15 cross-section images / 1 mm stent length), OCT endpoints are likely to reach significance at the level p <0.05, if the drop-out rate in follow-up does not exceed 20%. CURRENT STATUS The study is currently on-going and its termination is scheduled for February 2010. (ClinicalTrials.gov identifier: NCT01056744).

Churg-Strauss Syndrome Presenting with Cardiac Mass and Right Ventricular Obstruction

A 57‐year‐old woman presenting with asthma, hypereosinophilia, and generalized unspecific symptoms was diagnosed with Churg‐Strauss syndrome. Echocardiography revealed a cardiac mass obliterating the right ventricle and severely impaired left ventricular function, which were caused by endomyocardial fibrosis. Cortisone and cyclophosphamide therapy resulted in amelioration of left ventricular function and significant size reduction of the right ventricular mass. Copyright

Detection of coronary microembolization by Doppler ultrasound in patients with stable angina pectoris during percutaneous coronary interventions under an adjunctive antithrombotic therapy with abciximab: design and rationale of the High Intensity Transient Signals ReoPro (HITS-RP) study

BackgroundEmbolization of atherosclerotic debris from the rupture of a vulnerable atherosclerotic plaque occurs iatrogenically during percutaneous coronary interventions (PCI) and can induce myocardial necrosis. These microembolizations are detected as high intensity transient signals (HITS) using intracoronary Doppler technology.Presentation of the hypothesisIn the presented study we will test if abciximab (ReoPro®) infusion reduces high intensity transient signals in patients with stable angina pectoris undergoing PCI in comparison to standard therapy alone.Testing the hypothesisThe High Intensity Transient Signals ReoPro® (HITS-RP) study will enroll 60 patients. It is a prospective, single center, randomized, double-blinded, controlled trial. The study is designed to compare the efficacy of intravenous abciximab administration for reduction of microembolization during elective PCI. Patients will be randomized in a 1:1 fashion to abciximab or placebo infusion. The primary end point of the HITS-RP-Study is the number of HITS during PCI measured by intracoronary Doppler wire. Secondary endpoints are bleeding complications, elevation of cardiac biomarkers or ECG changes after percutaneous coronary interventions, changes in coronary flow velocity reserve, hs-CRP elevation, any major adverse cardio-vascular event during one month follow-up.Implications of the hypothesisThe HITS-RP-Study addresses important questions regarding the efficacy of intravenous abciximab administration in reducing microembolization and periprocedural complications in stable angina pectoris patients undergoing PCI.Trial registrationThe trial is registered under http://www.drks-neu.uniklinik-freiburg.de/drks_web/:DRKS00000603.

Cryptogenic left main thrombosis: successful mechanical clot retrieval with a self-expanding trapping device.

We present the case of a 52‐year‐old male with ST‐segment elevation myocardial infarction due to a spontaneous large left main thrombosis, without any angiographic evidence for coronary artery disease. After multiple unsuccessful attempts of thrombaspiration the large clot was mechanically retrieved by a flow restoration device that was primarily made for intracranial interventions. Intravascular ultrasound revealed marginal lumen narrowing after the intervention, but the final coronary angiogram showed a patent left main and there was no relevant stenosis remaining.

Vena contracta area for severity grading in functional and degenerative mitral regurgitation: a transoesophageal 3D colour Doppler analysis in 500 patients

Aims Vena contracta area (VCA3D), derived by 3D colour Doppler echocardiography, has already been validated against cardiac magnetic resonance imaging, but the number of clinical studies to define cut-off values for grading of mitral regurgitation (MR) is limited. Aim of the study was to assess VCA3D in a large population of patients with functional (FMR) and degenerative MR (DMR). Methods and results Transoesophageal echocardiography was performed in 500 patients with MR. The following 2D parameters were assessed for grading of MR: vena contracta width, effective regurgitant orifice area (EROAPISA), and regurgitation volume (RVPISA). VCA3D and the corresponding regurgitation volume (RVVCA) were quantified using 3D colour Doppler loop and CW Doppler tracing of the regurgitant jet. In 104 patients a 3D dataset of the left ventricle (LV) and the left ventricular outflow tract (LVOT) was acquired. As a reference method, regurgitation volume (RV3D) was calculated as difference between LV overall and LVOT stroke volumes. For prediction of severe MR, VCA3D yielded higher values of area under the ROC curve compared to EROAPISA (overall patient group 0.98 for VCA3D vs. 0.90 for EROAPISA, P < 0.001; FMR group 0.97 for VCA3D vs. 0.92 for EROAPISA, P = 0.002). RVVCA correlated closer with RV3D compared to RVPISA (r = 0.96 for RVPISA, r = 0.79 for RVPISA). Conclusion This study delivers cut-off values for VCA3D in patients with different types of MR. VCA3D is a robust parameter for quantification of MR, showing a good correlation with the reference method using 3D datasets of LV.

ST-segment Elevation Following Cardioversion of Atrial Fibrillation in the Emergency Department: Unmasked Myocardial Infarction due to Left Main Coronary Artery Plaque Rupture or Unspecific Finding?

Atrial fibrillation (AF) is a frequent reason for emergency department visits. According to current guidelines either rate- or rhythm-control are acceptable therapeutic options in such situations. In this report, we present the complicated clinical course of a patient with AF and a rapid ventricular response. Because of paroxysmal AF, the patient was on chronic oral anticoagulation therapy with warfarin. Pharmacological treatment was ineffective to control ventricular rate, and immediate synchronized electrical cardioversion was performed. One hour later, the patient complained of chest pain in combination with marked ST-segment elevation in the anterior leads. Cardiac catheterization with optical coherence tomography disclosed plaque rupture in the left main coronary artery without other significant stenosis. Stent implantation was performed successfully. During the course of the hospital stay, the patient remained asymptomatic and the ST-segment elevations resolved. However, despite treatment with amiodarone it was not possible to keep the patient permanently in sinus rhythm. Therefore, a biventricular pacemaker was implanted and AV node ablation performed.