Thomas Butz

Two-dimensional strain and strain rate imaging of the right ventricle in adult patients before and after percutaneous closure of atrial septal defects

AIMSnEchocardiographic speckle tracking or two-dimensional (2D) strain analysis is a new tool to assess myocardial function. This prospective controlled study evaluates systolic right ventricular (RV) function by 2D strain in adult patients with atrial septal defect (ASD) before and 3 months after percutaneous closure.nnnMETHODS AND RESULTSnAssessment of global longitudinal strain (GLS), global longitudinal strain rate (GLSR), and regional peak systolic strain (PSS) of right ventricle was performed in 33 ASD patients. The data were compared with those from 34 age-matched adults with patent foramen ovale. Before percutaneous closure, mean GLS was significantly increased in comparison to control group, and significantly reduced after closure. Analysis of regional PSS showed significant decrease in the lateral apical, lateral mid, and septal apical segments. GLSR was not influenced by ASD closure.nnnCONCLUSIONnTwo-dimensional strain appears to be helpful also for the assessment of RV function and its response to correction of volume overload.

Scanning electron microscopic analysis of different drug eluting stents after failed implantation: From nearly undamaged to major damaged polymers†

Background: Implantation of drug eluting stents (DES) in tortuous and/or calcified vessels is much more demanding compared with implantation of bare metal stents (BMS) due to their larger diameters. It is unknown whether drug eluting stent coatings get damaged while crossing these lesions. Methods: In 42 patients (34 male, 68.1 ± 10 years) with 45 calcified lesions (15.9 mm ± 7.9 mm), DES could not be implanted, even after predilatation. Diabetes was present in 19 patients (45 %). Sixty‐one stents were used; 19 Cypher select™, 18 Taxus Liberté™, 10 CoStar™, 5 Endeavor RX™, 4 Xience V™. 3 Janus Carbostent™, 1 Yukon Choice S™, and 1 Axxion™ DES. The entire accessible surface area of these stents, in either the unexpanded and expanded state, were examined with an environmental scanning electron microscope (XL30 ESEM, Philips) to evaluate polymer or surface damage. Results: The polymers of Taxus Liberte, Cypher Select, Xience V, CoStar, and Janus DES were only slightly damaged (less than 3% of surface area), whereas the Endeavor RX Stents showed up to 20% damaged surface area. In DES without a polymer (Yukon and Axxion), it could be shown that most of the stent surface (up to 40%) were without any layer of drug. Conclusion: Placement of drug eluting stents in tortuous vessels and/or calcified lesions could cause major surface damage by scratching and scraping of the polymer or drug by the arterial wall, even before implantation. There were remarkable differences among the stents examined, only minor damage with the Cypher, Taxus Costar, Janus, and Xience V, whereas the Endeavor, the Yukon, and the Janus DES showed large areas of surface injury.

How to diagnose cardiac amyloidosis early: impact of ECG, tissue Doppler echocardiography, and myocardial biopsy.

Aims.u2003To detect cardiac amyloidosis (CA) earlier, it is inevitable to improve diagnostic strategies. Methods and results.u2003The impact of ECG, echocardiography including tissue Doppler imaging (TDI) and strain, and myocardial biopsies was evaluated in 30 patients (63% (nu2009=u200919) men, mean age 66u2009±u20098 years, NYHA 3.0u2009±u20090.5, 73% with prior myocardial decompensation), in whom we proved CA. Amyloid was confirmed by apple-green birefringence under polarised light, and the causing protein by immunohistochemical examinations. Genetic analyses excluded familial CA. All patients (AL-lambda (nu2009=u200922), AL-kappa (nu2009=u20093), senile amyloidosis (nu2009=u20095)) had echocardiographic signs of restrictive cardiomyopathy (RCM), typical TDI and strain parameters (Eseptal; E′ lateralu2009<u20098 cm/s; E/E′u2009>u20098; S ≤9 cm/s; global longitudinal strain (GLS) −7.9u2009±u20093.8%). Pericardial effusions were present in 63% of patients. ECGs were suspicious in many patients: 19 (63%) had low-voltage, 23 (77%) reduced R waves in V1–V4, and 57% both. Abnormalities, retrospectively had been present for 0.5–4 years. Twenty (67%) patients died 232u2009±u2009268 [2–1020] days after CA was diagnosed, but 502u2009±u2009333 [30–1440] days after the first symptom. Conclusion.u2003Accurate ECG evaluations, careful echocardiographic search for RCM, reduced strain/strain rates, and general indications to myocardial biopsies with correct analyses are needed to diagnose CA.

Pulmonary Vein Isolation in 2012: Is It Necessary to Perform a Time Consuming Electrophysical Mapping or Should We Focus on Rapid and Safe Therapies? A Retrospective Analysis of Different Ablation Tools

Background: Pulmonary Vein Isolation (PVI) is evolving as an established treatment option in atrial fibrillation (AF). Different fluoroscopy-guided ablation devices exist either on the basis of expandable circumferential and mesh designs with mapping and ablation of pulmonary vein potentials, or of a balloon technology, a “single shot” device with a purely anatomical approach. Systematic comparisons between procedure duration (PD), fluoroscopy time (FT) and clinical outcome in using different ablation tools are lacking in the literature. Methods: In a single center retrospective analysis, 119 PVI procedures were performed between August 2008 and March 2011 in paroxysmal AF (PAF, 59.7%) and persistent AF (persAF, 40.3%) patients with mean age of 59.4±10.3 years and history of AF since 8.1±9.7 months. The PVI procedures were evaluated by comparing PD and FT using I) the High Density Mesh Mapper (HDMM), II) the High Density Mesh Ablator (HDMA), and III) the Arctic Front® Cryoballoon. The primary endpoints were FT and PD, the secondary endpoint was procedural safety and efficacy in short- and longterm follow-up. Results: The procedures performed for 119 patients (63.0 % male) included 42 PVIs with the HDMM (35.3 %), 47 with the HDMA (39.5 %) and 30 with the cryoballoon (25.2 %). Comparing the 30 first procedures in groups of 10 in the HDMM and HDMA group, PD and FT fell in the HDMM group (PD from 257.5 to 220.9 min and FT from 80.5 to 67.3 min, both p < 0.05) as well as in the HDMA group (PD from 182.9 to 147.2 min and FT from 41.02 to 29.1 min, both p < 0.05). In the cryoballoon group, there was a steep learning curve with a steady state after the first 10 procedures (PD and FT decreased significantly from 189.5 to 138.1 min and 36.9 to 27.3 min, p values 0.005 and 0.05 respectively). With respect to recurrence of AF in a 24 months follow up, the HDMM and cryoballoon group showed comparable results with ~72% of patients free of arrhythmias. None of the patients died due to severe complications, or suffered a hemodynamic relevant pericardial effusion and/or stroke. Impairment of the phrenic nerve was observed in three patients. Conclusion: Use of the cryoballoon technology was associated with a steep learning curve and a reduced PD and FT; the long-term outcome was similar compared with the HDMM group. The efficacy and safety of the devices but also PD and FT should be respected as the strongest indicators of the quality of ablation. Further studies with long time follow-ups will show if the time for correct mapping of the PV potentials is a price we should be willing to pay or if we should adopt a “wait-and-see” attitude referring the AF recurrence.

Pericardial Effusion With Beginning Cardiac Tamponade Caused by a Spontaneous Coronary Artery Rupture

A 65-year-old man was admitted to his local hospital with troponin-positive acute coronary syndrome. The patient developed signs of acute heart failure and was immediately transferred to our center.nnEchocardiography demonstrated a pericardial mass (8×5 cm) with compression of the right atrium (Figure 1 and online-only Data Supplement Movie I) and a reduced contractility of the posterior left ventricular wall. Magnetic resonance imaging demonstrated a pericardial hematoma that was incompressible, not vascularized, and impinging on the right atrium (Figure 2 and online-only Data Supplement Movie II). nnnnFigure 1. Echocardiographic 4-chamber view with …

Echocardiography-Guided Percutaneous Aspiration of a Large Pericardial Cyst

A 42-year-old man was admitted with exertional breathlessness (New York Heart Association class II) and atypical chest pain. These symptoms were caused by a growing pericardial cyst situated in the left cardiophrenic angle, which had been diagnosed by chest radiography 17 years earlier (Figure 1A). Transthoracic echocardiography confirmed the presence of a large fluid-filled cyst within the pericardial space and excluded any compression of the left ventricular free wall by the cyst (Figure 2). Magnetic resonance imaging revealed …

Percutaneous septal ablation after unsuccessful surgical myectomy for patients with hypertrophic obstructive cardiomyopathy.

ObjectiveTo evaluate the long-term outcome of percutaneous septal ablation (PTSMA) after a previous myectomy.BackgroundMyectomy usually results in symptomatic improvement and reduction of dynamic obstruction in hypertrophic obstructive cardiomyopathy patients (HOCM-pts.). However, a few pts. remain with severe symptoms and obstruction, and need additional interventions.MethodsWe reviewed our database of 450 pts. who underwent PTSMA in our institution, and identified 11 (7 women, 4 men, mean age: 50xa0±xa014xa0years) with residual or recurrent NYHA class symptoms ≥III and significant left ventricular outflow obstruction (LVOTO) despite a previous myectomy 4xa0±xa05xa0years ago. In-hospital and follow-up data covering 6xa0±xa04xa0years, focusing on mortality and morbidity, symptoms, exercise capacity, and echocardiographic measures were collected.ResultsPTSMA was performed by injection of 3.6xa0±xa02.9xa0ml of alcohol. There was no peri-procedural or late death in this cohort. CK peaked at 614xa0±xa0434xa0U/l. In addition to two pts. who already had a pacemaker implanted, two more (18%) who both had pre-existing left bundle branch block were pacemaker-dependent after PTSMA. During follow-up, 9 pts. (81%) reported significant and stable improvement. Two pts. (18%) developed progressive class III symptoms until their last follow-up, one of these together with persistent AF and a non-fatal stroke, the other received an ICD for primary prophylaxis and entered our pre-transplant program. Echo-Doppler showed sustained LVOTO elimination without global LV dilatation in all cases.ConclusionsPTSMA is an effective non-surgical option for treating symptoms and residual or recurrent LVOTO after a previous surgical myectomy. The high rate of conduction disturbances in this post-surgical cohort translated into a higher rate of pacemaker dependency after PTSMA.

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.

Echocardiac features simulating hypertrophic obstructive cardiomyopathy in a patient with pheochromocytoma

diagnosis of hypertrophic obstructive cardiomyopathy (HOCM) for further treatment, e.g. surgical myectomy or percutaneous septal ablation [2]. He had a long-standing, severe hypertension under triple anti-hypertensive drug therapy (b-blockers, diurectics and urapidil). He described variable symptoms with dyspnea NYHA functional class III and palpitations. Transthoracic echocardiography showed a hyperdynamic left ventricle with asymmetric hypertrophy. Left ventricular wall thickness was measured with 22 mm at the septum and with 12 mm at the free lateral wall. A systolic anterior motion of the mitral valve apparatus with short contact of the anterior leaflet with the septum could be detected and was associated with mild mitral regurgitation. By transesophageal echocardiography a friction lesion could be revealed in the region of the septal-mitral contact. Dynamic left ventricular outflow tract obstruction was observed, with a peak instantaneous gradient of 40 mmHg increasing to 100 mmHg with a Valsalva maneuver (Fig. 1a). Coronary artery disease was ruled out by coronary angiography. The left ventricular angiogram showed a hypertrophic left ventricle with slight axis deviation. Since a secondary form of hypertension was not convincingly ruled out, an additional sonography of the abdomen was performed which detected a mass superior to the left renal pole. An abdominal CT scan revealed a left adrenal tumor, 5 cm · 8 cm · 6 cm in diameter (Fig. 2). Serum metanephrine (1,202 ng/l, normal range: <130 ng/l), serum normetanephrine (1,234 ng/l, normal range: <300 ng/l) and urine metanephrine (119 ug/d, normal range: <20 ug/d) levels were significantly elevated. Urine vanillylmandelic acid (8.7 mg/d, normal range: <12 mg/d) and normetanephrine (33 ug/d, normal range: 10–100 ug/d) were within normal ranges. A I-MIBG-scintigram showed marked uptake in one single location corresponding to the tumor of the left adrenal gland (Fig. 3). This constellation was highly suggestive of pheochromocytoma. The cardiac procedures were thus postponed, and the patient underwent laparascopic Smita R. Jategaonkar Thomas Butz Wolfgang Burchert Dieter Horstkotte Lother Faber Echocardiac features simulating hypertrophic obstructive cardiomyopathy in a patient with pheochromocytoma

Coronary artery kinking with poststenotic ectasia: multislice computed tomography completes diagnosis: a review of the literature.

By describing the way of diagnosis, we report a case of coronary artery kinking associated with poststenotic dilatation. We give a review of the literature considering the different coronary morphology variations, etiological differential diagnosis, and the preferable terminology.