Tomáš Honěk

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Lower alcohol dose reduces size of infarction and has comparable hemodynamic and clinical outcome

Patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM) are considered to be good candidates for percutaneous transluminal septal myocardial ablation (PTSMA). However, there is ongoing discussion regarding the optimal dose of alcohol injected into target septal artery and the impact of infarct sizes on the clinical and hemodynamic outcome. Thirty‐four patients with symptomatic HOCM receiving maximum medical therapy were consecutively enrolled. Patients were randomized in a 1:1 ratio into one of the two arms according to dose of injected alcohol during echocardiography‐guided PTSMA procedure. Clinical, electrocardiographic, and echocardiographic evaluation were performed 6 months after the procedure in all the patients. Both groups of patients matched in all clinical and echocardiographic data. The dose of alcohol injected was 1.6 ± 0.4 and 3.4 ± 0.9 (P < 0.001) with subsequent peak of CK‐MB 1.9 and 3.2 μkat/L (P < 0.05) in group A and B, respectively. There was a correlation between amount of injected alcohol and the peak of CK‐MB (r = 0.58; P < 0.01), whereas no significant relationship (r = 0.16; P = NS) was documented between the peak of CK‐MB and left ventricular outflow gradient at follow‐up. At 6‐month follow‐up, both groups of patients were not significantly different with regard to symptoms or electrocardiographic and echocardiographic findings. In conclusion, this study suggests that the low dose (1– 2 ml) of alcohol injected into target septal branch reduces size of necrosis. Moreover, the low dose is probably as safe and efficacious as usually used doses (2–4 ml). Catheter Cardiovasc Interv 2004;63:231–235.

Outcome of patients after alcohol septal ablation with permanent pacemaker implanted for periprocedural complete heart block

Highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) irresponsive to medical therapy are treated with surgical myectomy, dual-chamber pacing or alcohol septal ablation(ASA). Based on single-center studies or national registries it seems that both short- and long-term outcomes of ASA are acceptable. The most frequent major complication associated with ASA is the mostly self-terminating complete heart block (CHB) that occurs in 20–50% of patients and requires permanent pacemaker implantation in 9–20% of all ASA patients [2,3]. Accordingly, this retrospective study was undertaken to evaluate the long-term outcome of patients who underwent early permanent pacemaker implantation due to post-ASA CHB.

Early remodelling of left ventricle and improvement of myocardial performance in patients after percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy

BACKGROUND Percutaneous transluminal septal myocardial ablation (PTSMA) reduces left ventricular outflow (LVOT) gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM) and leads to symptomatic improvement. Effects of PTSMA on left ventricular performance are currently unknown. The purpose of this study was to evaluate changes in the left ventricular performance using Doppler index of myocardial performance (sum of isovolumic contractile and relaxation times divided by left ventricular ejection time) and left ventricular remodelling after PTSMA for HOCM. METHODS Twenty-five patients with symptomatic HOCM underwent echocardiography-guided PTSMA procedure. Clinical and echocardiographic data were collected at baseline and 3 months after PTSMA. RESULTS PTSMA procedures were uneventful, in one patient (4%), pacemaker implantation was needed for sustained complete heart block after the procedure. At 3-month follow-up, the maximal LVOT gradient decreased from 68+/-39 to 18.6+/-12 mmHg (P<0.001), the provoked maximal LVOT gradient decreased from 128.8+/-59 to 25+/-21.4 mmHg (P<0.001), and basal septal thickness decreased from 21.7+/-4 to 15.2+/-3 mm (P<0.001). The improvement of the index of myocardial performance (from 0.65+/-7 to 0.56+/-11; P<0.001) was associated with neither significant change in left ventricular ejection fraction nor left ventricular ejection time. There was no significant difference in the left ventricular dimension at baseline and at follow-up. All patients reported a significant improvement in symptoms at follow-up, the mean NYHA class decreased from 2.6+/-0.7 to 1.4+/-0.7 (P<0.001), and the number of patients suffering from episodes of syncope or attacks of dizziness decreased from 13 to two during the 3-month follow-up. CONCLUSIONS PTSMA is a safe, effective and reproducible method in the treatment of highly symptomatic patients with HOCM. This procedure results in a significant relief of symptoms associated with decrease in LVOT gradient and thickness of basal interventricular septum. Positive changes in Doppler IMP suggest possible improvement of left ventricular function.

Effect of catheter-based patent foramen ovale closure on the occurrence of arterial bubbles in scuba divers.

OBJECTIVES This study sought to evaluate the effect of catheter-based patent foramen ovale (PFO) closure on the occurrence of arterial bubbles after simulated dives. BACKGROUND PFO is a risk factor of decompression sickness in divers due to paradoxical embolization of bubbles. To date, the effectiveness of catheter-based PFO closure in the reduction of arterial bubbles has not been demonstrated. METHODS A total of 47 divers (age 35.4 ± 8.6 years, 81% men) with a PFO (PFO group) or treated with a catheter-based PFO closure (closure group) were enrolled in this case-controlled observational trial. All divers were examined after a simulated dive in a hyperbaric chamber: 34 divers (19 in the PFO group, 15 in the closure group) performed a dive to 18 m for 80 min, and 13 divers (8 in the PFO group, 5 in the closure group) performed a dive to 50 m for 20 min. Within 60 min after surfacing, the presence of venous and arterial bubbles was assessed by transthoracic echocardiography and transcranial color-coded sonography, respectively. RESULTS After the 18-m dive, venous bubbles were detected in 74% of divers in the PFO group versus 80% in the closure group (p = 1.0), and arterial bubbles were detected in 32% versus 0%, respectively (p = 0.02). After the 50-m dive, venous bubbles were detected in 88% versus 100%, respectively (p = 1.0), and arterial bubbles were detected in 88% versus 0%, respectively (p < 0.01). CONCLUSIONS No difference was observed in the occurrence of venous bubbles between the PFO and closure groups, but the catheter-based PFO closure led to complete elimination of arterial bubbles after simulated dives. (Nitrogen Bubble Detection After Simulated Dives in Divers With PFO and After PFO Closure; NCT01854281).

Survival of Patients 50 Years of Age After Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

BACKGROUND The long-term efficacy and safety of alcohol septal ablation (ASA) has recently been demonstrated. However, there is still debate about the outcome of younger patients who should be treated using myectomy, according to American College of Cardiology Foundation/American Heart Association guidelines. The aim of this study was to evaluate the long-term outcome of patients ≤ 50 years of age after ASA for hypertrophic obstructive cardiomyopathy (HOCM). METHODS We retrospectively evaluated consecutive, highly symptomatic patients aged ≤ 50 years with HOCM who underwent ASA. RESULTS Institutional databases of 3 cardiovascular centres identified 290 patients with HOCM who underwent ASA; 75 (26%) of them were aged ≤ 50 years at the time of their first ASA. Median duration of follow-up was 5.1 years (range, 0.1-15.4 years). Four patients (5%) died during the study period (438 patient-years; the annual mortality rate was 0.91%; 95% confidence interval [CI], 0.25-2.34%; the annual mortality rate combined with the first appropriate implantable cardioverter-defibrillator discharge was 1.43%; 95% CI, 0.52-3.10%). Survival free of all-cause mortality at 1, 5, and 10 years was 97% (95% CI, 89-99%), 94% (95% CI, 84-98%), and 94% (95% CI, 84-98%), respectively. CONCLUSIONS Results of this first study focused on HOCM patients aged ≤ 50 years who underwent ASA suggest a low risk of all-cause death or appropriate implantable cardioverter-defibrillator discharge in the long-term follow-up.

Effect of conservative dive profiles on the occurrence of venous and arterial bubbles in divers with a patent foramen ovale: A pilot study

Patent foramen ovale (PFO) is a risk factor for decompression sick-ness(DCS)indiversduetoparadoxicalembolizationofnitrogenbubblesformed in peripheral blood during decrease of ambient pressure [1].Inour previous study we have demonstrated that catheter-based PFO clo-sure prevented right-to-left shunting of bubbles and might preventDCS recurrence [2]. However, the question of PFO closure is still debat-able [3].Also,randomizedclinicaldataarelackinginthis field.Therefore,the majority of divers are currently not referred for PFO closure, andvarious conservative dive profiles (CDP) are recommended to preventunprovoked DCS (i.e., without violation of decompression regimen) [4].Unfortunately, to date, the safety of these CDP has not been tested in di-verswithPFO.Theaimofthisstudywastotesttheeffectofdivetimeandascent rate restrictions on the occurrence of venous and arterial bubblesin diverswith PFO after simulated dives.We compareda standardly rec-ommended no-decompression dive [5] and a stricter regimen withslower ascent to the same control dive, which was previously used totest the efficacy of catheter-based PFO closure [2].Wescreenedatotalof 532 consecuti vediversforPFOusingtranscra-nialcolorcodedsonography(TCCS).ThediagnosisofPFOwascon firmedbytransesophagealechocardiography.Forty-sixdivers(36.4±10 years;72% men) with a significant PFO (grade 3 according to the internationalconsensus criteria [6]) who had previously not undergone PFO closurewere enrolled in this pilot study. All divers performed a simulated diveto 18 m in a hyperbaric chamber. Divers were randomized into threegroups: group A (n = 13; 36.5 ± 9 years; 77% men) performed a stan-dard Buhlmann regimen no-decompression dive (dive time 51 min,ascent rate 10 m/min), group B (n = 14, 40.9 ± 12 years; 64% men)performed the same regimen with a slower ascent (51 min, 5 m/min),and a control group (n = 19; 33.0 ± 8 years; 74% men) performed astaged-decompression dive according to the US Navy decompressionregimen (80 min, 9 m/min, decompression stop 7 min at 3 m). Within60 min of surfacing, the presence of venous and arterial bubbles wasassessed. Venous bubbles were assessed by pulse wave Doppler in therightventricularout flowtract (RVOT),andarterialbubbles byTCCS dur-ing native breathing and after Valsalva maneuvers, as described previ-ously [2]. The study was approved by the local ethics committee and allpatients signed an informed consent.In all divers, visualization of RVOT and the middle cerebral artery waspossible. The occurrence of arterial and venous bubbles is summarized inFig. 1. There was significantly lower occurrence of venous bubbles ingroups A and B compared to controls (for group A, 31% vs. 74%, p =0.03; for group B, 14% vs. 74%, p b 0.01). The reduction in arterial bubbleoccurrencewasnotsigni ficantingroupAcomparedtocontrols,buttherewas elimination of arterial bubbles in group B (for group A, 8% vs. 32%,p = 0.42;forgroupB,0%vs.32%,p= 0.03).Therewasnosigni ficantdif-ference in venous or arterial bubble occurrence between groups A and B(venous, 31% vs. 14%, p = 0.38; arterial, 8% vs. 0%, p = 0.48). All diverswere observed for any DCS symptoms 24 h after the simulated dive. Inthe control group transient neurological symptoms (headache, unusualfatigue, and transitory visual disturbances) were present in 21% of divers,no DCS symptoms were observed in group A (p = 0.13) or B (p = 0.12).Generally, the aim of our research is to stratify the risk of DCS indiverswithPFOandtofindtheoptimalmanagementstrategyforsymp-tomatic divers, including potential catheter-based PFO closure. In our

Treatment of recurrent coronary rupture by implantation of three coronary stent-grafts

The authors report a case of recurrent left anterior descending artery rupture during coronary interventions in a 70-year-old man. Coronary artery rupture was treated successfully by percutaneous coronary stent-graft implantation. Based on this experience, the authors advise against repeat angioplasty of a coronary artery which has ruptured during a prior intervention. Membrane-covered stents should be the first choice in the treatment of life-threatening coronary artery rupture. (Int J Cardiovasc Intervent 2003; 5: 88-91)

Patent Foramen Ovale in Recreational and Professional Divers: An Important and Largely Unrecognized Problem

Patent foramen ovale (PFO) is associated with an increased risk of decompression sickness (DCS) in divers that results from a paradoxical embolization of nitrogen bubbles. The number of scuba divers worldwide is estimated in the millions, and the prevalence of PFO is 25%-30% in adults. It is interesting that despite these numbers, many important issues regarding optimal screening, risk stratification, and management strategy still remain to be resolved. Recently published data suggest the possible effectiveness of both PFO closure and conservative diving measures in preventing arterial gas embolization. This review aims to introduce the basic principles of physiology and the pathophysiology of bubble formation and DCS, summarize the current literature on PFO and diving, and review the possibilities of diagnostic workup and management.

Catheter-based endovenous laser ablation of saphenous veins in the treatment of symptomatic venous reflux: Early results

Uvod: Katetrizacni endovenozni laserova ablace (EVLA) je běžně uživana alternativa chirurgicke lecby varixů dolnich koncetin a postupně se stava metodou volby. V teto observacni studii jsme si kladli za cil prokazat, zda je tato metoda bezpecna a proveditelna v souboru neselektovaných pacientů a zda je možno provest ablaci vice segmentů v ramci jednoho výkonu.Metodika: V obdobi od unora 2010 do března 2016 byla provedena EVLA celkem v 1 209 žilnich segmentech u 1 117 po sobě nasledujicich pacientů (74 % ženy) s žilnim refluxem. Průměrna siře žily byla 8,5 mm (5-25 mm). Vsechny operace byly provedeny ambulantně v mistnim znecitlivěni s užitim tumescentni anestezie. Vsechny výkony byly provedeny s peroperacni sonografickou kontrolou.Výsledky: Casný uzavěr byl uspěsný u 98,8 % intervenovaných žil. Casna recidiva byla pozorovana u deviti pacientů (15 žilnich segmentů). Vsechny byly uspěsně casně reintervenovany a uzavřeny. Mezi přiciny neuplneho uzavěru patřily zejmena běžně zname rizikove faktory (antikoagulacni terapie, varikoflebitida v anamneze). Nebyla zjistěna korelace s větsim průměrem žily. U sesti pacientů byl pozorovan prolaps trombu do lumen hluboke femoralni žily. Vsechny připady byly uspěsně vyleceny po týdnu lecby nizkomolekularnim heparinem. Byl zaznamenan pouze jeden připad nizkorizikove plicni embolie u pacientky, ktera neuposlechla režimova doporuceni.Zavěr: Endovenozni laserova ablace velke a male safeny a jejich velkých větvi v lecbě symptomatickeho žilniho refluxu je proveditelna, bezpecna a reprodukovatelna metoda. Uzavěr žilnich segmentů nebyl limitovan jejich průměrem ani poctem.