Wolfgang Zeh

Pulmonary capillary wedge pressure during exercise and long-term mortality in patients with suspected heart failure with preserved ejection fraction

AIMS In patients with suspected heart failure with preserved ejection fraction (HFpEF), invasive exercise testing may be considered when measurements at rest are inconclusive. However, the prognostic impact of invasive exercise testing is uncertain, so far. METHODS AND RESULTS We retrospectively analysed mortality in 355 patients [mean age 61.2 ± 11.3 years, 235 (66.2%) women] with unexplained dyspnoea and suspected HFpEF. During an invasive haemodynamic stress test pulmonary capillary wedge pressure (PCWP) at rest and the PCWP response to exercise, expressed as the ratio of PCWP at peak exercise to workload normalized to body weight [PCWL (mmHg/W/kg)], were recorded. Both PCWP at rest and PCWL were significant and independent predictors of long-term mortality. Adding PCWL to PCWP at rest improved reclassification of patients into survivors or non-survivors with a net reclassification improvement (NRI) of 0.56 (95% CI: 0.29-0.83; P < 0.001). Ten-year mortality was 6.6% in subjects with low PCWP at rest (≤ 12 mmHg) and low PCWL (≤ 25.5 mmHg/W/kg); 28.2% in patients with low PCWP and high PCWL and 35.2% in those with high PCWP and high PCWL. Compared with patients with low PCWP and low PCWL, the adjusted hazard ratio for mortality was 2.37 (95% CI: 1.09-5.17; P = 0.029) for the low-PCWP/high-PCWL group and 4.75 (95% CI: 1.90-11.84; P < 0.001) for patients with high PCWP/high PCWL. CONCLUSION In patients with suspected HFpEF, invasive exercise testing substantially improves prediction of long-term mortality. An excessive rise of PCWP during exercise despite normal PCWP at rest is associated with increased mortality and may be considered as early HFpEF.

Cusp thrombosis after transcatheter aortic valve replacement detected by computed tomography and echocardiography

An 86-year-old male underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis with an Edwards Sapien 29 mm XT valve and percutaneous coronary intervention simultaneously. Periprocedural transoesophageal echocardiography (TOE) showed good positioning and expansion of the prosthesis with only minor paravalvular insufficiency. Routine …

The porcine valve type predicts obstructive thrombosis beyond the first three postoperative months in bioprostheses in the aortic position

BACKGROUND Obstructive thrombosis of bioprosthetic valves is considered rare but may have dramatic consequences for the individual patient including repeat valve replacement, thrombolysis, or long-term anticoagulation. Whether the risk of obstructive thrombosis is dependent on the type of bioprosthesis (porcine versus bovine pericardial) is uncertain. METHODS AND RESULTS Between 2007 and 2012 a total of 1751 patients received a single stented bioprosthesis in the aortic valve position, 749 (43%) were porcine and 1002 (57%) bovine. During a mean follow-up of 3.4±1.9years, obstructive thrombosis (identified by an increase in mean pressure gradient≥20mm Hg or a decrease in velocity ratio≥0.05 and confirmed by either ECG-gated computer tomography, a return to baseline of stenosis parameters under treatment with a vitamin K antagonist, or histology in case of reoperation) was diagnosed in 17 patients with a porcine (2.3%) and none with a bovine valve (p<0.001). The cumulative probability of developing an obstructive thrombosis was significantly higher in patients with a porcine valve (p<0.001 log-rank test). Adjusting for differences in baseline variables and stratification by the estimated propensity score showed that strata with a high probability of receiving a bovine valve had the highest number of obstructive thrombosis in porcine valves. These findings were further confirmed in a Poisson model and a competing risk model including all-cause mortality. Treatment of obstructive thrombosis with a vitamin K antagonist was safe and effective in 15/17 patients. CONCLUSION The porcine valve type is an independent predictor of obstructive thrombosis in bioprostheses in the aortic position.

Angiographic assessment of cardiac allograft vasculopathy: results of a Consensus Conference of the Task Force for Thoracic Organ Transplantation of the German Cardiac Society.

Angiograms of cardiac transplant (HTx) recipients were to be evaluated in a ring experiment and a joint consensus on criteria of angiographic evaluation of coronary arteries of HTx patients was to be reached. Twenty‐four coronary angiograms from 11 hospitals were circulated. One hundred eighty‐eight blinded evaluations were returned. A joint evaluation by six experienced cardiologists was used as reference standard and a consensus evaluation form was developed. Significant lesions (stenosis 75%, 50% in the left main coronary artery) were diagnosed in 10/23 abnormal coronary angiograms (41.7%). Interventional revascularization was recommended in 8/10 (80%). In 21 coronary angiograms distal pruning was found and in 11/21 (52.4%) cases with distal pruning occlusion of at least one peripheral vessel was detected. The best kappa value (0.7) was found for the presence of at least one clinically significant stenosis. Agreement on the site and grade of local stenosis was much less. Some agreement on remodeling was found in assessing diffuse narrowing in the LCA (kappa = 0.371, P < 0.001). The kappa value for peripheral obliteration was 0.331 (P = 0.001). Angiographic evaluation of cardiac allograft vasculopathy, particularly of diffuse and peripheral disease and remodeling, needs standardization. This should be performed in a downward compatible improvement process.

Reducing the ischemic time of donor hearts will decrease morbidity and costs of cardiac transplantations

With liberalization of donor eligibility criteria, donor hearts are being harvested from remote locations, increasing ischemic times. The aim of this study was to examine the effect of total ischemic time (TIT) on length of stay in the intensive care unit (LOS in ICU) and its economic consequences. The study population included recipients without prior mechanical support undergoing heart transplantation between 1998 and 2008 at a single institution. The mean age of the 72 recipients (56 men, 16 women) was 50.6 years (range 15-68 years) and the mean donor age was 41.5 years (range 11-61 years). The median TIT was 181.2 min (range 107-243) and median LOS in ICU was 11.5 days (range 3-107 days). There was a statistically significant linear relationship between TIT and LOS in ICU r(72)=0.317, P=0.004. Each 5 min and 38 s of TIT equated to one more day in ICU. An ischemic time >180 min was associated with higher LOS in ICU, renal failure, and a more frequent use of nitric oxide in our cohort. For longer distance harvesting, the reduction of TIT by the fastest possible transport (learjet, helicopter) would have economic advantages with regards to the high cost of treatment in ICU.

Valve Thrombosis 7 Months After Transcatheter Aortic Valve Implantation

A 77-year old man underwent transcatheter aortic valve implantation for severe aortic stenosis with a 29-mm Edwards-Sapien XT aortic valve bioprosthesis. Periprocedural transesophageal echocardiography and computed tomography showed good positioning and expansion of the prosthesis with only minor transvalvular insufficiency. On a routine checkup 7 months later, echocardiography and computed tomography showed a high transvalvular gradient suggestive of valve thrombosis, which could not be treated with warfarin. Because of rapid deterioration of the patients clinical condition, an urgent surgical valve replacement was performed 4 weeks after initial notice of the valve thrombosis. The patients postoperative stay was uneventful.

4D-Cine CT imaging of a bicuspid pulmonary valve

A 71-year-old woman underwent diagnostic workup for progressive shortness of breath. Transthoracic echocardiography showed a dilated main pulmonary artery (MPA) and an anomalous configuration of the pulmonary valve. CT revealed a bicuspid pulmonary valve (BPV) and confirmed MPA dilation. Further congenital abnormalities were excluded. An isolated finding of BPV is rather rare. To our knowledge we present the first 4-dimensional CT images of a BPV. As in this case, 4-dimensional cine cardiac CT may be helpful to reveal the underlying cause of MPA dilation.

Mental health status of patients with mechanical aortic valves, with ventricular assist devices and after heart transplantation

OBJECTIVES Mental health is a complex construct, in which emotional aspects and quality of life are central. It has been assessed in patients after heart transplantation (HTX) and occasionally in those with ventricular assist devices (VADs). However, there are no studies that compare patients with primary HTX with those with HTX ending VAD support. Evidence for patients with mechanical aortic valve replacement is also limited. We compared mental outcome for these four groups for the first time. We also focused on the question of an artificial device, i.e. VAD or mechanical aortic valve, as distinct from a biological graft, i.e. HTX. METHODS Two questionnaires were applied: The Hospital Anxiety and Depression Scale, the German version consists of two subscales for anxiety and for depression, and the 12-item Short Form Health Survey, the German version contains two subscales for physical and for mental performance measuring quality of life. We included 46 patients with mechanical aortic valve replacement, 55 after HTX and 22 on support by a long-term VAD. The HTX group consisted of 38 patients with primary HTX and 17 recipients who were on VAD support before transplantation. The index operation was at least 6 months ago. RESULTS HTX patients suffered less from anxiety and depression than patients with mechanical aortic valve replacement or those on VAD. HTX patients had higher scores on the physical scale but not on the mental component scale of the 12-item Short Form Health Survey compared with VAD patients. Conversely, patients with mechanical aortic valve replacement did worse with regard to mental but not physical performance compared with HTX patients. VAD and mechanical aortic valve replacement patients differed only with regard to physical condition, but not with regard to anxiety, depression and mental status. HTX patients with and without VAD support before transplantation achieved similar values on all scales. Mental scales did not correlate with age or time after surgery. CONCLUSIONS HTX patients had the best outcome compared with the other groups with respect to mental health. Mechanical aortic valve replacement patients did not differ from VAD patients with respect to anxiety, depression and mental quality of life scores. Mechanical aortic valve replacement patients might be more in need of psychological support than expected. Further, VAD patients who undergo HTX reach similar mental and physical results when compared with patients with primary HTX, i.e. they seem to cope well in the long run.

Body image after heart transplantation compared to mechanical aortic valve insertion

Abstract Objective: Heart transplantation (HT) obviously affects body image and integrity. However, there are very few empirical data post-transplant. Methods: In a cross-sectional study, 57 HT patients were compared with 47 subjects with mechanical aortic valve replacement (AVR) using the Dresden-Body-Image questionnaire (DKB) and specific questions regarding integration of the organ/device. In addition, affective symptoms and quality of life (QoL) were assessed (12-Item Short-Form Health Survey and Hospital Anxiety and Depression Scale, HADS). Results: DKB-35 scores did not differ. HT patients scored higher than AVR on specific questions regarding integration of the organ/device. AVR patients showed more affective disturbance and lower mental QoL than HT subjects. Affective scores correlated negatively with body image scores. Seventeen percent of all patients showed psychological distress (HADS scores >8). Conclusions: HT patients integrated the new organ well – and even better than AVR subjects did with the device. In general, our data corroborate a good adaptation process, in particular in HT patients. Similar to other reported data, a subgroup of 15–20% of patients shows stronger mental distress, including body image problems. These must be identified and treated by professionals. Patients with AVR deserve more attention in the future.