Tushar Chatterjee

Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance.

Purpose: To examine the clinical consequences and/or potential need for postinterventional transposition after stent-graft occlusion of the left subclavian artery (LSA). Methods: The records of 171 consecutive patients (128 men; mean age 60.2±13.2 years, range 20–83) undergoing elective stent-graft repair in the thoracic aorta were reviewed to identify intentional endograft coverage of the ostial LSA, as documented by transesophageal echocardiography and/or aortography. Patients were treated for subacute type B dissection, true aneurysm, pseudoaneurysm, or previously operated type A dissection with persistent false lumen flow in the descending aorta. Among the 171 cases, 22 (12.9%) patients were identified with stent-graft occlusion of the LSA. Results: A systolic blood pressure differential existed between the right (138.4±14.0 mmHg) and the left (101.8±21.0 mmHg; p<0.05) arms after occlusion of the LSA. No patient showed a malperfusion syndrome during postinterventional hospitalization. During a mean follow-up of 24.0±15.8 months, 15 (68.2%) patients remained completely asymptomatic, with no functional deficit or temperature differential between the arms, while 7 patients reported mild symptoms of a subclavian steal syndrome. However, no patient required any secondary surgical intervention. Conclusions: Stent-graft—induced occlusion of the ostial LSA was tolerated by all patients without chronic functional deficit. In the absence of stenotic vertebral and/or carotid arteries and with a documented intact vertebrobasilar system, prophylactic transposition of the LSA is not required prior to intentional stent-graft occlusion of the LSA.

Transcatheter transplantation of autologous skeletal myoblasts in postinfarction patients with severe left ventricular dysfunction.

Purpose: To report a case-controlled safety and feasibility study of transcatheter transplantation of autologous skeletal myoblasts as a stand-alone procedure in patients with ischemic heart failure. Methods: Six men (mean age 66.2±7.2 years) were eligible for transcatheter transplantation of autologous skeletal myoblasts cultured from quadriceps muscle biopsies. Six other men (mean age 65.7±6.3 years) were selected as matched controls (no muscle biopsies). A specially designed injection catheter was advanced through a femoral sheath into the left ventricle cavity, where myoblasts in solution (0.2 mL/injection) were injected into the myocardium via a 25-G needle. At baseline and in follow-up, both groups underwent Holter monitoring, a 6-minute walk test, New York Heart Association (NYHA) class determination, and echocardiography with dobutamine challenge. Results: Skeletal myoblast transplantation was technically successful in all 6 patients with no complications; 19±10 injections were performed per patient (210times106±150times106 cells implanted per patient). Left ventricular ejection fraction (LVEF) rose from 24.3%±6.7% at baseline to 32.2%±10.2% at 12 months after myoblast implantation (p=0.02 versus baseline and p<0.05 versus controls); in matched controls, LVEF decreased from 24.7%±4.6% to 21.0%±4.0% (p = NS). Walking distance and NYHA functional class were significantly improved at 1 year (p= 0.02 and p= 0.001 versus baseline, respectively), whereas matched controls were unchanged. Conclusions: Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe, and promising. Scrutiny with randomized, double-blinded, multicenter trials appears warranted.

Technique of interventional repair in adult aortic coarctation

Surgical treatment of aortic coarctation has increased life expectancy and reduced mortality. Unfortunately, the average lifespan after repair remains only 35 to 50 years, and significant morbidity persists as a result of aneurysm formation, hypertension, accelerated coronary disease, and stroke. Follow-up studies have revealed restenosis rates of 30% and persistent hypertension at rest and during exercise, sometimes with compromised cardiac function. The less invasive nature of nonsurgical repair using transcatheter therapies has led to balloon angioplasty and, recently, stent implantation as an emerging concept for the treatment of aortic coarctation. This review focuses on advances in the management, current indication, and techniques of interventional repair in aortic coarctation.

Effect of Antibiotic Treatment in Patients With Postimplantation Syndrome After Aortic Stent Placement

INTRODUCTION AND OBJECTIVES Postimplantation syndrome that can develop after stent placement is characterized by fever, leukocytosis and an elevated C-reactive protein level or by coagulation disturbances, or by a combination of these features. It is a transient condition that frequently appears following endovascular treatment. At present, no data are available on the effect of antibiotics on postimplantation syndrome after placement of a thoracic endoprosthesis. METHODS This prospective single-center study involved 40 patients. Of these, 20 received peri-interventional (for 24 hours) antibiotic treatment with cefuroxime, 20 mg/ kg three times per day, while 20 received prolonged (for 7 days) treatment at the same dosage. Peripheral blood samples were taken before the intervention and 6 h, 12 h, 24 h, 48 h, 3 days, 5 days, and 7 days after. RESULTS There was no significant difference in clinical or laboratory findings between the two treatment strategies, and subsequent changes in clinical and laboratory parameters over time were similar in the two groups. All parameters returned to baseline values within 7 days. CONCLUSIONS Prolonging antibiotic treatment beyond the day of endovascular intervention was not observed to provide any short- or long-term clinical benefit in patients with postimplantation syndrome, given that all blood samples were sterile.

Perkutane intramyokardiale Implantation von autologen Myoblasten bei ischämischer Kardiomyopathie

Hintergrund und Ziel:Die intrakardiale Transplantation von Zellen gilt als experimentelles therapeutisches Konzept bei ischämischer Kardiomyopathie. Im Gegensatz zur intramyokardialen Injektion von Myoblasten während einer Bypassoperation oder Implantation eines linksventrikulären Assist-Device wurde in dieser Studie die perkutane Implantation von autologen Myoblasten als singulärer Eingriff bei sechs Patienten mit ischämischer Kardiomyopathie hinsichtlich Sicherheit und Effektivität untersucht. Sechs Patienten mit gematchten demographischen und klinischen Parametern dienten als Kontrollgruppe.Methodik und Ergebnisse:Die perkutane Implantation von Myoblasten konnte bei allen Patienten ohne Komplikationen durchgeführt werden. Pro Patient wurden 19 ± 10 Injektionen appliziert, was einer Zellzahl von 210 × 106 ± 150 × 106 Zellen pro Patient entspricht. Die linksventrikuläre Pumpfunktion (LVEF) der myoblastenbehandelten Gruppe stieg von 24,3 ± 6,7% auf 33,2 ± 10,2% nach 6 Monaten an (p = 0,02 im Vergleich zum Ausgangswert). Im gleichen Zeitraum zeigte die Kontrollgruppe keine Veränderungen. Im 6-min-Gehtest ließ sich eine Zunahme der Gehstrecke von 371 ± 49 m auf 493 ± 86 m nach einem 1/2 Jahr in der behandelten Gruppe nachweisen (p = 0,003 im Vergleich zum Ausgangswert), während sich die Gehstrecke der unbehandelten Kontrollgruppe nicht wesentlich veränderte (von 360 ± 24 m auf 369 ± 26 m nach einem 1/2 Jahr). Damit einhergehend zeigte sich eine Verbesserung der NYHA-Klasse von 3,17 ± 0,41 auf 1,67 ± 0,82 in der implantierten Gruppe (p = 0,001 im Vergleich zum Ausgangswert), während die NYHA-Klasse der vergleichenden Kontrollgruppe im gleichen Beobachtungszeitraum bei 3 ± 0 unverändert blieb.Schlussfolgerung:Die perkutane kathetergestützte Implantation von in vitro amplifizierten autologen Myoblasten bei Patienten mit ischämischer Kardiomyopathie ist technisch durchführbar und könnte neue therapeutische Perspektiven eröffnen; eine abschließende Beurteilung der Effizienz erfordert größere, randomisierte, doppelblinde Studien mit längerem Follow-up.Background and Purpose:Cell transplantation is emerging as a novel approach for the treatment of end-stage cardiac disease. In contrast to most human studies using intramyocardial injection of myoblasts during coronary artery bypass grafting (CABG) or left ventricular assist device implantation, the authors investigated both safety and feasibility of transcatheter transplantation of autologous skeletal myoblast as a standalone procedure in six patients with ischemic heart failure, and compared them to six control patients matched for demographic and clinical characteristics.Methods and Results:Skeletal myoblast transplantation by catheter-based injection was technically successful in all six patients with no complications; 19 ± 10 injections were performed/patient corresponding to 210 × 106 ± 150 × 106 cells/patient. Postinterventional Holter monitoring and ICD memory check documented three episodes of ventricular tachycardia in two patients after myoblast implantation, one at 30 days in patient 1, and two at 27 and 41 days in patient 2. Patient 1, although asymptomatic, was subsequently subjected to oral amiodarone since he refused an ICD; in patient 2 each tachycardia was terminated by a previously implanted ICD. Both patients were followed for 6 months without any evidence of repeat ventricular arrhythmia. Matched control patients revealed one episode of ventricular tachycardia in three patients each of which was aborted by ICD discharge within 6 months of observation. None of the documented ventricular tachycardias in both groups occurred in relation to any new myocardial necrosis which was excluded by ECG and cardiac enzymes. Left ventricular ejection fraction (LVEF) rose from 24.3 ± 6.7% at baseline to 33.2 ± 10.2% 6 months after myoblast implantation (p = 0.02 vs. baseline); in matched controls LVEF decreased from 24.7 ± 4.6% to 22.2 ± 6.2% (p < 0.05 vs. myoblasttreated group at 6 months). Moreover, the 6-min walk test revealed an improvement from 371 ± 49 m to 493 ± 86 m 6 months after implantation (p = 0.003 vs. baseline and p = 0.015 vs. controls), whereas matched controls were unchanged at 360 ± 24 m and 369 ± 26 m, respectively. Accordingly, NYHA functional class improved from 3.17 ± 0.41 to 1.67 ± 0.82 within 6 months of myoblast implantation (p = 0.001 vs. baseline and p = 0.01 vs. controls), while NYHA class remained unchanged at 3 ± 0 in matched controls.Conclusion:Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe and promising and, thus, warrants the scrutiny of larger randomized double-blind multi-center trials with longer follow-up surveillance.

Der extrakardiale Thoraxschmerz

Zusammenfassung.Die differentialdiagnostische Abklärung und adäquate Therapie eines Patienten mit Thoraxschmerzen stellen an den behandelnden Arzt hohe fachliche Anforderungen. Lebensbedrohliche Erkrankungen als Ursache eines extrakardialen Thoraxschmerzes, wie die Aortendissektion, der Pneumothorax und die Lungenembolie, müssen neben dem kardial bedingten Thoraxschmerz des akuten Koronarsyndroms rasch nachgewiesen oder differentialdiagnostisch ausgeschlossen werden. Ziel dieser Übersicht ist die Darstellung von Ursachen und rationellen diagnostischen Strategien zur Abklärung des extrakardialen Thoraxschmerzes.Abstract.In patients with an acute chest pain syndrome the primary requirement is to diagnose or exclude acute myocardial ischemia or myocardial infarction. However, only 30% of patients admitted and evaluated for chest pain ultimately reveal the diagnosis of acute coronary syndrome.Traditionally, the initial evaluation of patients presenting with chest discomfort or pain to an emergency department or any general practice involves the triad of history, physical examination, and ECG and chest film evaluation. With the diagnostic routine of bedside enzymatic tests for cardiac biomarkers, it has become easier to identify acute coronary syndromes, but at the same time more compelling to pinpoint other differential diagnoses, once coronary syndromes are excluded.When a cardiac origin of any nonsuggestive chest pain syndrome has been excluded, a broad spectrum of other causes for noncardiac chest pain needs to be evaluated. Potential underlying disorders are listed in this overview and grouped according to pathoanatomic origin into aortic, respiratory, and gastroesophageal disorders, musculoskeletal pathology, and somatization disorders. This article reviews both symptoms and diagnostic pathways in patients with noncardiac chest pain, and eventually offers a rational strategy for an efficacious workup of a wide spectrum of important differential diagnoses.In patients with an acute chest pain syndrome the primary requirement is to diagnose or exclude acute myocardial ischemia or myocardial infarction. However, only 30% of patients admitted and evaluated for chest pain ultimately reveal the diagnosis of acute coronary syndrome.Traditionally, the initial evaluation of patients presenting with chest discomfort or pain to an emergency department or any general practice involves the triad of history, physical examination, and ECG and chest film evaluation. With the diagnostic routine of bedside enzymatic tests for cardiac biomarkers, it has become easier to identify acute coronary syndromes, but at the same time more compelling to pinpoint other differential diagnoses, once coronary syndromes are excluded. When a cardiac origin of any non-suggestive chest pain syndrome has been excluded, a broad spectrum of other causes for noncardiac chest pain needs to be evaluated. Potential underlying disorders are listed in this overview and grouped according to pathoanatomic origin into aortic, respiratory, and gastroesophageal disorders, musculoskeletal pathology, and somatization disorders. This article reviews both symptoms and diagnostic pathways in patients with noncardiac chest pain, and eventually offers a rational strategy for an efficacious workup of a wide spectrum of important differential diagnoses.

Quadrikuspide Aortenklappe als ungewöhnliche Genese einer ausgeprägten Aortenklappeninsuffizienz

ZusammenfassungHintergrund:Eine Aortenklappeninsuffizienz, unterteilbar in eine akute sowie eine chronische Form, kann unterschiedlicher Genese sein. Während bei der akuten Form häufig eine Endokarditis, eine Typ-A-Aortendissektion sowie Traumata eine Rolle spielen, kann die chronische Form u.a. durch eine angeborene Klappenanomalie bedingt sein. Hierbei stellt die quadrikuspide Aortenklappe die weitaus seltenste Form dar. Die Diagnose wird meist zufällig während der echokardiographischen Untersuchung, im Rahmen von kardiochirurgischen Eingriffen oder postmortal gestellt.Fallbeschreibung:Berichtet wird über eine 44-jährige Patientin mit seit 2 Jahren bestehender progredienter Belastungsdyspnoe. In der klinischen Untersuchung fand sich ein lautes Diastolikum im zweiten Interkostalraum rechts bei einem Blutdruck von 170/60 mmHg. Die echokardiographische Untersuchung ergab die Diagnose einer Aortenklappeninsuffizienz III° bei angeborener quadrikuspider Aortenklappe. Nach operativem Aortenklappenersatz nach Bentall und anschließender oraler Antikoagulation wurde die Patientin im weiteren Verlauf beschwerdefrei.Schlussfolgerung:Das Auftreten einer quadrikuspiden Aortenklappe, häufig assoziiert mit einer Aortenklappeninsuffizienz, ist sehr selten. Bei klinischem Verdacht sollte eine echokardiographische Untersuchung veranlasst werden. Die spezielle Therapie kann anhand der klinischen Beschwerden und der objektiven Parameter festgelegt werden. Bei geringer Aortenklappeninsuffizienz und leichten klinischen Beschwerden ist ein medikamentös-konservatives Vorgehen gerechtfertigt. Bei Auftreten einer höhergradigen Aortenklappeninsuffizienz sowie klinischen Zeichen einer kardialen Dekompensation wird eine chirurgische Therapie empfohlen.AbstractBackground:Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem.Case Report:A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well.Conclusion:Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.BACKGROUND Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem. CASE REPORT A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well. CONCLUSION Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.

Quadricuspid aortic valve as an unusual cause of severe aortic regurgitation

ZusammenfassungHintergrund:Eine Aortenklappeninsuffizienz, unterteilbar in eine akute sowie eine chronische Form, kann unterschiedlicher Genese sein. Während bei der akuten Form häufig eine Endokarditis, eine Typ-A-Aortendissektion sowie Traumata eine Rolle spielen, kann die chronische Form u.a. durch eine angeborene Klappenanomalie bedingt sein. Hierbei stellt die quadrikuspide Aortenklappe die weitaus seltenste Form dar. Die Diagnose wird meist zufällig während der echokardiographischen Untersuchung, im Rahmen von kardiochirurgischen Eingriffen oder postmortal gestellt.Fallbeschreibung:Berichtet wird über eine 44-jährige Patientin mit seit 2 Jahren bestehender progredienter Belastungsdyspnoe. In der klinischen Untersuchung fand sich ein lautes Diastolikum im zweiten Interkostalraum rechts bei einem Blutdruck von 170/60 mmHg. Die echokardiographische Untersuchung ergab die Diagnose einer Aortenklappeninsuffizienz III° bei angeborener quadrikuspider Aortenklappe. Nach operativem Aortenklappenersatz nach Bentall und anschließender oraler Antikoagulation wurde die Patientin im weiteren Verlauf beschwerdefrei.Schlussfolgerung:Das Auftreten einer quadrikuspiden Aortenklappe, häufig assoziiert mit einer Aortenklappeninsuffizienz, ist sehr selten. Bei klinischem Verdacht sollte eine echokardiographische Untersuchung veranlasst werden. Die spezielle Therapie kann anhand der klinischen Beschwerden und der objektiven Parameter festgelegt werden. Bei geringer Aortenklappeninsuffizienz und leichten klinischen Beschwerden ist ein medikamentös-konservatives Vorgehen gerechtfertigt. Bei Auftreten einer höhergradigen Aortenklappeninsuffizienz sowie klinischen Zeichen einer kardialen Dekompensation wird eine chirurgische Therapie empfohlen.AbstractBackground:Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem.Case Report:A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well.Conclusion:Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.BACKGROUND Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem. CASE REPORT A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well. CONCLUSION Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.

Quadrikuspide Aortenklappe als ungewöhnliche Genese einer ausgeprägten Aortenklappeninsuffizienz@@@Quadricuspid Aortic Valve as an Unusual Cause of Severe Aortic Regurgitation

ZusammenfassungHintergrund:Eine Aortenklappeninsuffizienz, unterteilbar in eine akute sowie eine chronische Form, kann unterschiedlicher Genese sein. Während bei der akuten Form häufig eine Endokarditis, eine Typ-A-Aortendissektion sowie Traumata eine Rolle spielen, kann die chronische Form u.a. durch eine angeborene Klappenanomalie bedingt sein. Hierbei stellt die quadrikuspide Aortenklappe die weitaus seltenste Form dar. Die Diagnose wird meist zufällig während der echokardiographischen Untersuchung, im Rahmen von kardiochirurgischen Eingriffen oder postmortal gestellt.Fallbeschreibung:Berichtet wird über eine 44-jährige Patientin mit seit 2 Jahren bestehender progredienter Belastungsdyspnoe. In der klinischen Untersuchung fand sich ein lautes Diastolikum im zweiten Interkostalraum rechts bei einem Blutdruck von 170/60 mmHg. Die echokardiographische Untersuchung ergab die Diagnose einer Aortenklappeninsuffizienz III° bei angeborener quadrikuspider Aortenklappe. Nach operativem Aortenklappenersatz nach Bentall und anschließender oraler Antikoagulation wurde die Patientin im weiteren Verlauf beschwerdefrei.Schlussfolgerung:Das Auftreten einer quadrikuspiden Aortenklappe, häufig assoziiert mit einer Aortenklappeninsuffizienz, ist sehr selten. Bei klinischem Verdacht sollte eine echokardiographische Untersuchung veranlasst werden. Die spezielle Therapie kann anhand der klinischen Beschwerden und der objektiven Parameter festgelegt werden. Bei geringer Aortenklappeninsuffizienz und leichten klinischen Beschwerden ist ein medikamentös-konservatives Vorgehen gerechtfertigt. Bei Auftreten einer höhergradigen Aortenklappeninsuffizienz sowie klinischen Zeichen einer kardialen Dekompensation wird eine chirurgische Therapie empfohlen.AbstractBackground:Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem.Case Report:A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well.Conclusion:Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.BACKGROUND Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem. CASE REPORT A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well. CONCLUSION Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.

Perkutane intramyokardiale Implantation von autologen Myoblasten bei ischämischer Kardiomyopathie@@@Percutaneous Transplantation of Autologous Myoblasts in Ischemic Cardiomyopathy

Hintergrund und Ziel:Die intrakardiale Transplantation von Zellen gilt als experimentelles therapeutisches Konzept bei ischämischer Kardiomyopathie. Im Gegensatz zur intramyokardialen Injektion von Myoblasten während einer Bypassoperation oder Implantation eines linksventrikulären Assist-Device wurde in dieser Studie die perkutane Implantation von autologen Myoblasten als singulärer Eingriff bei sechs Patienten mit ischämischer Kardiomyopathie hinsichtlich Sicherheit und Effektivität untersucht. Sechs Patienten mit gematchten demographischen und klinischen Parametern dienten als Kontrollgruppe.Methodik und Ergebnisse:Die perkutane Implantation von Myoblasten konnte bei allen Patienten ohne Komplikationen durchgeführt werden. Pro Patient wurden 19 ± 10 Injektionen appliziert, was einer Zellzahl von 210 × 106 ± 150 × 106 Zellen pro Patient entspricht. Die linksventrikuläre Pumpfunktion (LVEF) der myoblastenbehandelten Gruppe stieg von 24,3 ± 6,7% auf 33,2 ± 10,2% nach 6 Monaten an (p = 0,02 im Vergleich zum Ausgangswert). Im gleichen Zeitraum zeigte die Kontrollgruppe keine Veränderungen. Im 6-min-Gehtest ließ sich eine Zunahme der Gehstrecke von 371 ± 49 m auf 493 ± 86 m nach einem 1/2 Jahr in der behandelten Gruppe nachweisen (p = 0,003 im Vergleich zum Ausgangswert), während sich die Gehstrecke der unbehandelten Kontrollgruppe nicht wesentlich veränderte (von 360 ± 24 m auf 369 ± 26 m nach einem 1/2 Jahr). Damit einhergehend zeigte sich eine Verbesserung der NYHA-Klasse von 3,17 ± 0,41 auf 1,67 ± 0,82 in der implantierten Gruppe (p = 0,001 im Vergleich zum Ausgangswert), während die NYHA-Klasse der vergleichenden Kontrollgruppe im gleichen Beobachtungszeitraum bei 3 ± 0 unverändert blieb.Schlussfolgerung:Die perkutane kathetergestützte Implantation von in vitro amplifizierten autologen Myoblasten bei Patienten mit ischämischer Kardiomyopathie ist technisch durchführbar und könnte neue therapeutische Perspektiven eröffnen; eine abschließende Beurteilung der Effizienz erfordert größere, randomisierte, doppelblinde Studien mit längerem Follow-up.Background and Purpose:Cell transplantation is emerging as a novel approach for the treatment of end-stage cardiac disease. In contrast to most human studies using intramyocardial injection of myoblasts during coronary artery bypass grafting (CABG) or left ventricular assist device implantation, the authors investigated both safety and feasibility of transcatheter transplantation of autologous skeletal myoblast as a standalone procedure in six patients with ischemic heart failure, and compared them to six control patients matched for demographic and clinical characteristics.Methods and Results:Skeletal myoblast transplantation by catheter-based injection was technically successful in all six patients with no complications; 19 ± 10 injections were performed/patient corresponding to 210 × 106 ± 150 × 106 cells/patient. Postinterventional Holter monitoring and ICD memory check documented three episodes of ventricular tachycardia in two patients after myoblast implantation, one at 30 days in patient 1, and two at 27 and 41 days in patient 2. Patient 1, although asymptomatic, was subsequently subjected to oral amiodarone since he refused an ICD; in patient 2 each tachycardia was terminated by a previously implanted ICD. Both patients were followed for 6 months without any evidence of repeat ventricular arrhythmia. Matched control patients revealed one episode of ventricular tachycardia in three patients each of which was aborted by ICD discharge within 6 months of observation. None of the documented ventricular tachycardias in both groups occurred in relation to any new myocardial necrosis which was excluded by ECG and cardiac enzymes. Left ventricular ejection fraction (LVEF) rose from 24.3 ± 6.7% at baseline to 33.2 ± 10.2% 6 months after myoblast implantation (p = 0.02 vs. baseline); in matched controls LVEF decreased from 24.7 ± 4.6% to 22.2 ± 6.2% (p < 0.05 vs. myoblasttreated group at 6 months). Moreover, the 6-min walk test revealed an improvement from 371 ± 49 m to 493 ± 86 m 6 months after implantation (p = 0.003 vs. baseline and p = 0.015 vs. controls), whereas matched controls were unchanged at 360 ± 24 m and 369 ± 26 m, respectively. Accordingly, NYHA functional class improved from 3.17 ± 0.41 to 1.67 ± 0.82 within 6 months of myoblast implantation (p = 0.001 vs. baseline and p = 0.01 vs. controls), while NYHA class remained unchanged at 3 ± 0 in matched controls.Conclusion:Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe and promising and, thus, warrants the scrutiny of larger randomized double-blind multi-center trials with longer follow-up surveillance.