Werner Scholtz

Transcatheter closure of patent foramen ovale in patients with cerebral ischemia

OBJECTIVESnThe present study was conducted to determine the safety of the transcatheter closure of a patent foramen ovale (PFO) in patients with cryptogenic cerebral ischemia and the midterm follow-up of recurrent thromboembolic events after interventional PFO closure.nnnBACKGROUNDnCurrent therapeutic options for stroke prevention in patients with PFO and a history of thromboembolic events include chronic antithrombotics and more invasive treatments such as surgical closure or minor invasive transcatheter permanent closure of the PFO. Promising preliminary and pilot data with the Amplatzer Septal Occluder or the PFO-Star Occluder have been reported. Systematic and long-term data are still missing.nnnMETHODSnA total of 276 consecutive patients with a PFO and a history of at least one thromboembolic event were recruited in four medical centers and underwent percutaneous PFO closure with the PFO-Star device. Follow-up data were analyzed over an average of 15.1 months, equivalent to 345 patient-years.nnnRESULTSnThe implantation was successful in all 276 patients. Peri-interventional reversible complications included transient ST-segment elevations (1.8%) and transient ischemic attack (TIA) (0.8%). Two devices have been removed surgically. During follow-up the annual recurrence rate of thromboembolic events was 1.7% for TIA, 0% for stroke and 0% for peripheral emboli.nnnCONCLUSIONSnInterventional PFO closure with the PFO-Star device appears to be a reliable and promising technique resulting in a low recurrence rate of thromboembolic events, especially stroke in patients with a history of cryptogenic ischemia presumably due to paradoxical embolization. To our knowledge, this is the largest coherent and prospective study for interventional PFO closure.

Cardiac remodeling and effects on exercise capacity after interventional closure of atrial septal defects in different adult age groups

BackgroundInterventional closure of atrial septal defects (ASD) has become a standard procedure in pediatric and adult patients. We report immediate and mid-term results in different adult age groups.MethodsA retrospective analysis of 332 patients undergoing percutaneous ASD closure between 1998 and 2008 was performed. Beside echocardiographic and hemodynamic measurements, the NYHA functional class was assessed before and after ASD closure. The peak oxygen uptake (VO2peak) was available in a subgroup of 154 patients.ResultsThe different age groups did not differ significantly in shunt volume or defect diameter, but a significant increase could be detected in mean pulmonary arterial pressure, mean left atrial pressure and pulmonary vascular resistance (PVR9 with increasing age). Right ventricular enlargement was present in all age groups, but the degree of enlargement increased with age. Transcatheter ASD closure was successful in 99.4%, major adverse events occurred in four patients (1.2%). At 3xa0months from closure, 123 patients reported an improvement, 7 of worsening and 163 of no change in their functional capacity. A significant increase in VO2peak could be registered in all subgroups after ASD closure. When classified by shunt volume no change could be detected in VO2peak in the patients with a Qp:Qsxa0<xa02, whereas patients with a Qp:Qsxa0>xa02 had a highly significant VO2peak increase.ConclusionPatients benefit from interventional closure of hemodynamically significant ASD regardless of their age. However, the defect should be repaired as early as possible to prevent hemodynamic complications, such as the development of pulmonary hypertension and cardiac arrhythmias.

Sleep-disordered breathing in patients undergoing transfemoral aortic valve implantation for severe aortic stenosis

BackgroundWe examined the prevalence of sleep-disordered breathing (SDB) in patients with severe aortic valve stenosis (AS) and the impact of transfemoral aortic valve implantation (TAVI) on SDB.Methods79 patients underwent cardiorespiratory polygraphy (PG) before TAVI (CoreValve™), 62 of them a second PG after the procedure.ResultsForty-nine (62xa0%) patients had obstructive sleep apnea (OSA), 25 (32xa0%) central sleep apnea (CSA), and 5 (6xa0%) presented without significant SDB (apnea–hypopnea index (AHI)xa0<xa05/h). Among the 62 patients evaluated before and after TAVI, 36 (58xa0%) had OSA, 22 (36xa0%) CSA, and 4 patients (7xa0%) no SDB. AHI was significantly higher in CSA patients than in OSA patients (34.5xa0±xa018.3 vs. 18.0xa0±xa012.6/h, pxa0<xa00.001). Successful TAVI had a significant impact on CSA but not on OSA: CSA patients with optimal TAVI results experienced a significant reduction in central respiratory events (AHI 39.6xa0±xa019.6–23.1xa0±xa016.0/h, pxa0=xa00.035), while no changes were detected in OSA patients (AHI 18.8xa0±xa013.0–20.25xa0±xa013.4/h, pxa0=xa00.376). In contrast, in patients who developed at least moderate periprosthetic aortic regurgitation (ARxa0>xa0I), CSA increased significantly (AHI 26.3xa0±xa013.2–39.2xa0±xa018.4/h, pxa0=xa00.036), whereas no acute change was seen in patients with OSA (AHI 10.5xa0±xa07.8–12.5xa0±xa05.0/h, pxa0=xa00.5).ConclusionOSA and CSA are prevalent in more than 90xa0% of patients undergoing TAVI for severe aortic valve stenosis. Successful TAVI had no significant impact on OSA but improved CSA. In case of an acute change from pressure overload (aortic stenosis) to acute volume overload (aortic regurgitation after TAVI), central, but not obstructive, sleep apnea deteriorated.

Impact of closure devices on vascular complication and mortality rates in TAVI procedures

BACKGROUNDnCurrently two closure devices are available for the vascular access in TAVI procedures. Their impact on vascular complications and mid-term mortality is yet unknown.nnnMETHODSnBetween 2009 and 2014, 398 patients underwent TAVI TF procedures in which two different closure devices were used, Prostar® XL (n=215) and Perclose-Proglide® (n=183). In the cases with Prostar we used one device and in cases with Perclose-Proglide, two devices. The two groups were compared with respect to the criteria of the Valve Academic Research Consortium (VARC) II. The mean follow-up period was 679.7±481.8 (727) days.nnnRESULTSnThere were no significant differences in the baseline characteristics of both patient groups. In the Prostar® group, complications were more frequent (26.6% vs. 12.6%, p=0.005); in detail, these were bleeding (14.9% vs. 7.1%, [p]=0.02), suture rupture (4.7% vs. 1.3%, p=0.04), and pseudoaneurysms (10.2% vs. 1.2%, p<0.001). Multivariate regression analysis revealed two predictors for vascular complications: female sex (OR 2.3; 95% CI 1.3-3.8, p=0.002) and closure devices (OR 0.5; 95% CI 0.3-0.8, p=0.007) in favour of Proglide®. There was no significant difference in 30-day mortality (Prostar: 5.6±1.6% vs. Proglide: 4.9±1.6%). However, Kaplan-Meier survival analysis showed a significantly higher survival rate over the entire follow-up period for the Proglide® group (p=0.03).nnnCONCLUSIONnVascular complications occurred more often in the Prostar® group. Although 30-day mortality showed no significant difference between the groups, the mortality over complete follow-up was significantly lower in the Proglide® group.

Left ventricular adaptation after TAVI evaluated by conventional and speckle-tracking echocardiography.

OBJECTIVEnOur study aimed to evaluate myocardial adaption and outcome after transfemoral aortic valve implantation (TAVI TF) for severe aortic stenosis by LV ejection fraction (LVEF) and speckle tracking analysis.nnnMETHODS AND RESULTSnFrom 168 patients who underwent TAVI TF between 2010 and 2013 in our institution, n=95 with a follow-up period ≥3months were included and grouped (G) according to baseline left ventricular ejection fraction (LVEF; G1: LVEF<40%, G2: 40%-55%, G3: >55%). LV function was evaluated using conventional and speckle-tracking based parameters. Mortality was tracked up to 60months. Aortic valve orifice diameter and mean aortic gradient improved significantly after TAVI. LV dimensions and LVEF remained largely unchanged. Systolic function significantly improved in G1 (LVEF, p<0.001, global longitudinal strain [GLS], p=0.02) but deteriorated in G3 (LVEF, p=0.004, GLS, p=0.03). It did not change in G2. Diastolic function parameters improved significantly only in G3. Changes of LVEF and GLS were also statistically significant between G1 and G3 (LVEF p<0.0001, GLS p=0.004). Patients exhibited a higher survival rate with an LVEF increase >8% than with LVEF deterioration >8% (p=0.04). GLS changes had no significant impact on mortality.nnnCONCLUSIONnIn patient with aortic stenosis and LVEF impairment at baseline, TAVI results in an improved LVEF, while patients with a high LVEF at baseline experience a normalization of LVEF after TAVI. Independent of the baseline value, a deterioration of LVEF leads to a significant increase in mortality.

Right atrial hemangioma in modern cardiac imaging

Dr. med. Andreas Peterschröder Dr. med. Eva Fricke Institut für Radiologie, Nuklearmedizin und molekulare Bildgebung Herzund Diabeteszentrum NRW Ruhr-Universität Bochum Georgstr. 11 32545 Bad Oeynhausen, Germany Tel.: +49-57 31 / 97 18 29 Fax: +49-57 31 / 97 18 62 E-Mail: apeterschroeder@hdz-nrw.de efricke@hdz.nrw.de Prof. Dr. med. Ute Raute-Kreinsen Städt. Kliniken Bielefeld Mitte Institut für Pathologie Teutoburger Str. 50 33604 Bielefeld, Germany Tel.: +49-5 21 / 58 10 Fax: +49-5 21 / 5 81 20 99

Transcatheter Aortic Valve Implantation in Nonagenarians: Procedural Outcome and Mid-term Results

BACKGROUNDnFor nonagenarians with symptomatic severe aortic stenosis transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option. Therefore, the aim of this study was to evaluate the procedural outcomes and mid-term follow-up in this patient group and compare this to octogenarians.nnnMETHODSnFrom 1359 patients who underwent TAVI at our institution between March 2009 and February 2016, 82 patients were nonagenarians and 912 were octogenarians. In nonagenarians, mean age was 91.9±1.4years and compared to octogenarians showed a significantly higher logistic EuroScore (27.7±14.8% vs. 23.1±14.4, p=0.005) and STS Score (8.5±4.8% vs. 6.3±6.7, p=0.001).nnnRESULTSnThere were no significant differences with regard to stroke rate, pacemaker implantation rate and major vascular complications between the two groups. Thirty-day mortality was 9.8% in nonagenarians and 4.1% in octogenarians (p=0.04). At 1 year, all-cause mortality increased to 30.9% vs. 18.6% (n.s.).nnnCONCLUSIONnNonagenarians showed an increased periprocedural mortality during TAVI and higher mortality in follow-up compared to octogenarians. Age alone is not a predictive factor but indication for treatment should be carefully evaluated by the heart team on an individual basis.

Interventional ASD II closure in the presence of an abnormally localized left main coronary artery

Sirs: Catheter-interventional closure of a secundum atrial septal defect (ASD II) is a common procedure. Most of the defects are suitable for this technique. A variety of different occluders and sizes are available. In the presence of additional congenital cardiac malformations the intervention may be problematic or even inappropriate. As a congenital anomaly, the left main coronary artery (LCA) may arise near or out of the ostium of the right coronary artery (RCA). The localization of the LCA may then be in the anterior or posterior wall around the aortic valve (AV) annulus/aortic root. The coexistence of this anomaly with a secundum atrial septal defect is rare. To close the ASD under this condition [1, 2], surgery is the most common procedure. The alternative catheter-interventional closure is rarely performed, because a partly or even complete compression of the LCA may occur as the occluder may rest at or on the aortic wall and therefore also on the LCA [3]. However, interventional closure may be an alternative [4, 5], if there is enough distance between defect/occluder and the LCA. Contrary to ASD closure in normal coronary morphologies, it is of utmost importance that in this special case no part of the occluder touches the LCA when approaching the defect or is placed close to or even on the aortic wall. This is to prevent compression of the LCA, ending up in a coronary occlusion [4, 5]. While pushing the catheter/sheath forward, attention should be paid to the angle between catheter/sheath and the interatrial septum to avoid touching the LCA with the catheter tip to prevent coronary spasm [6] or even rupture. Additionally, maneuvering the catheter within the left atrium may also be critical for the same reasons when retracting the sheath with the partly developed occluder from the pulmonary vein area towards the defect [7]. We report on a 60-year-old male patient with an ASD II (Fig. 1a, b). The diameter of the defect is 16 mm, left-toright shunting 58 %, the rate of pulmonary/systemic flow is (Qp/Qs) 3.7/1. The pulmonary vascular resistance is normal. As additional anomaly a right-sided origin of the LCA was found (Fig. 1c, d). The LCA proceeded posteriorly around the aortic valve (AV) annulus. The patient’s clinic included right heart overload, vertigo, chronic atrial fibrillation, complete right bundle branch block, no cardiac decompensation. Transoesophageal echocardiography (TEE) was performed under local anaesthesia and mild sedation. Balloonsizing using the shunt-flow-stop technique revealed a defect width of 22 mm. To keep the size of the occluder as small as possible to prevent touching or compressing the LCA, a non-oversized ASD occluder (Amplatzer ASD occluder, 22 mm, St. Jude Medical Inc., St. Paul, USA) was implanted. The procedure was performed carefully under permanent monitoring of the LCA using 2D-/3DTEE and angiography to avoid compression of the LCA by the occluder during or after implantation. While retracting the developed left-sided part of the occluder towards the septum (IAS), the LCA was compressed mildly for a very short phase because of the acute angle between catheter Electronic supplementary material The online version of this article (doi:10.1007/s00392-015-0923-3) contains supplementary material, which is available to authorized users.

Aktueller Stand der kathetergestützten Aortenklappenimplantation

ZusammenfassungZur invasiven Therapie der symptomatischen hochgradigen Aortenklappenstenose hat sich die kathetergestützte Aortenklappenimplantation („transcatheter aortic valve implantation“, TAVI) bei ausgewählten Patienten als akzeptierte Alternative zum konventionellen Aortenklappenersatz (AKE) etabliert. Seit seiner Erstanwendung im Menschen 2002 wurde dieses Verfahren im Hinblick auf Patientenselektion, präoperative Diagnostik, Prothesendesigns und Implantationstechniken rasch weiterentwickelt. Aufgrund der guten Ergebnisse, die bislang erzielt wurden, wird eine Ausweitung der Indikation auf Patienten mit intermediärem Risiko diskutiert. Darüber hinaus wird, nicht unumstritten, von vielen Zentren eine „Transfemoral-first“-Strategie bevorzugt. Ziel dieses Beitrags ist es, einen Überblick über die aktuelle Praxis der TAVI zu geben und aktuelle Diskussionsthemen zusammenzufassen.AbstractFor selected patients, transcatheter aortic valve implantation (TAVI) has emerged as an accepted alternative to surgical aortic valve replacement for treatment of severe symptomatic aortic stenosis. The procedure has undergone a rapid evolvement since the first-in-man procedure in 2002. New devices have been introduced, implantation techniques modified and preoperative imaging modalities refined. Due to the favorable results achieved, the expansion of the indications for TAVI is the subject of current debate. Furthermore, a transfemoral-first approach is becoming favored more and more by many centers. The aim of this article is to give an update on current clinical practice and to summarize contemporary issues under debate.

A differentiated morphological parameter-coding system to describe the suitability of mitral valve stenoses intended for percutaneous valvotomy

Percutaneous balloon-mitral-valvotomy (PBMV) is an alternative to surgery in selected patients with mitral valve (MV) stenosis (MS). Applying echocardiography, suitability for PBMV is assessed by detailed morphological description. Echo-scores alone are suboptimal to describe MV morphology, because single parameters, important for a decision concerning PBMV, are not distinguishable out of a score number. The aim was to design a tool (coding-system), which combines a number for a stenotic MV like scores (for statistical options) and decodable, generally applied parameters describing the MS morphology. The reproducibility of the MS morphology using the coding-system has to be tested in 90 patients. A separate group of 297 patients (pts) with MS, scheduled for PBMV, should be investigated prospectively applying the coding-system and a comparable score. We chose the Wilkins score (WS) as representative of scores. The coding-system is designed as a parameter sequencing set consisting of 6 digits. The first digit indicates a decision code concerning suitability for PBMV. The following 5 digits indicate generally accepted morphological parameters, which are partially also used in the WS. Therefore, the MS morphology can be “read” retrospectively by decoding. 201/297 patients were found suitable for PBMV. Applying the coding-system all 201 suitable patients were correctly distinguished from 96 morphologically unsuitable patients. Astonishingly 48/96 of the rejected patients showed a WS ≤8 whereas 28/201 of the suitable patients demonstrated a WS >8. 25/28 of them showed a successful initial outcome. Applying the generally known threshold of “8” when predicting suitability of a MS, the WS demonstrated an initial success rate of 62xa0%, sensitivity of 0.87, specificity of 0.45, precision of 0.79, and accuracy of 0.78. Applying the coding-system, the initial success rate was 70.8xa0%, sensitivityxa0=xa00.96, specificityxa0=xa01.0, precisionxa0=xa01.0, and accuracyxa0=xa00.97. The coding-system is an advanced diagnostic aid, is statistically applicable, offers a decodable morphological description, includes a decision code regarding suitability for PBMV, and can be used for comparing different groups of patients with MS by calculating “mean morphologies” of groups.