Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

[Acute intervention for ST-elevation myocardial infarction]. / Akute Intervention beim ST-Streckenhebungsinfarkt.

Rapid revascularization of every presenting patient is the goal of modern therapy of ST-elevation myocardial infarction (STEMI). With respect to the current situation at least one half of all these patients will be treated medically using thrombolysis, prehospital or in hospital. Invasive diagnosis and revascularization (percutaneous intervention [PCI], coronary artery to bypass graft [CABG]) should be done promptly. Primary PCI performed in a timely manner by experienced interventional cardiologists in specialized centers is the best option in the management of patients with STEMI. Transfer PCI is an effective method of treatment for patients initially admitted to a hospital without PCI facilities and should be completed within 90 minutes of transfer time. Rescue-PCI following unsuccessful thrombolysis (< 50 % ST-resolution 90 minutes post thrombolysis) improves prognosis by restoring coronary flow. If planned immediate PCI after thrombolytic therapy is not indicated, PCI immediately after high dosage of glycoprotein IIb/IIIa-Inhibitors in combination with a high dose of clopidogrel may give good results.

[Secondary prevention after myocardial infarction]. / Sekundärprävention nach Myokardinfarkt.

A significant reduction in cardiovascular mortality has been achieved during the last decade. New techniques and materials for early coronary intervention have contributed significantly to reduce early mortality after myocardial infarction. Secondary prevention determines further progress; it combines evidence-based medical treatment as well as lifestyle modifications. ACE inhibitors, angiotensin receptor blockers, and beta-blocker positively affect elevated blood pressure, left ventricular remodeling, and electrical stability. Statins decrease LDL and increase HDL cholesterol. Acetylsalicylic acid and clopidogrel are indicated for antiplatelet therapy. Lifestyle modifications unite a diet rich in polyunsaturated fatty acids, moderate physical activity, weight reduction, and smoking cessation.

[Catheter embolisation into the pulmonary artery. Interventional therapy of a rare form of pulmonary embolism]. / Katheterembolisation in die Arteria pulmonalis. Interventionelle Therapie einer seltenen Form der Lungenembolie.

Embolisation of a foreign body is a rare cause of pulmonary embolism. We report on a 67 year old female suffering from colorectal cancer. To perform adjuvant chemotherapy a port system was inserted into the right subclavian vein. Routine chest radiography revealed a rupture of the venous port-system, which was embolised into the right pulmonary artery without clinical symptoms. The foreign body was removed without complications using a nitinol goose neck snare via a transfemoral approach and retrieved percutaneously. The reported procedure is safe, decreases operation and hospitalisation time and should therefore be performed in preference to surgical management whenever possible.

[Determinants of long-term follow-up after stent implantation in acute myocardial infarction]. / Determinanten des Langzeitverlaufes über drei Jahre nach Stent-Implantation bei akutem Myokardinfarkt.

Coronary stent implantation is an effective treatment of acute myocardial infarction. Little is known about long-term follow-up of patients undergoing stent implantation in the setting of acute myocardial infarction, since most studies restrict the follow-up to six months. The aim was to investigate the clinical follow-up of patients over a period of three years and to identify predictive factors of an adverse cardiovascular outcome. The study retrospectively analyzes a consecutive series of 204 patients receiving stent implantation in the setting of an acute myocardial infarction. Follow-up angiography was performed after 5+/-2 months following myocardial infarction analyzing the incidence of angiographic restenosis. Adverse cardiovascular outcome was defined as cumulative end point including death, myocardial infarction, coronary artery bypass grafting and PTCA/stent implantation of the target vessel occurring in the first three years following myocardial infarction. Multivariate analysis correlated clinical, procedural and angiographic variables with an adverse outcome. Restenosis occurred in 38% of patients. An adverse outcome was observed in 42% of patients. Multivariate analysis identified target vessel CABG, time to treatment >10 h, TIMI flow <3 after stent implantation, number of stents >1, male gender, multivessel disease and arterial hypertension as independent predictors of an adverse cardiovascular outcome. Critical consideration of these risk factors may help to identify patients who are poor candidates for stent implantation in acute myocardial infarction. However, further investigation is required to corroborate the results of this investigation on determinants of a three year follow-up after stent implantation in acute myocardial infarction.

Risk factors for the development of restenosis following stent implantation of venous bypass grafts.

OBJECTIVE: To analyse the variables involved in the high restenosis rate following stent implantation in coronary artery bypass grafts. DESIGN: A retrospective analysis of a consecutive group of patients attending a tertiary centre. PATIENTS: The long term angiographic outcome of 219 stent implantations for individual lesions performed in 191 patients was investigated. Multivariate analysis correlated clinical, procedural, and angiographic variables with the incidence of angiographic restenosis, defined as diameter stenosis > 50% at follow up. RESULTS: Angiographic restenosis was observed in 34% of lesions treated. Multiple logistic regression analysis defined diabetes mellitus (odds ratio 6.91, 95% confidence interval (CI) 2.43 to 9.69), graft recanalisation (2.89, 95% CI 1.18 to 6.63), lesion at the aortic anastomosis (6.98, 95% CI 2.77 to 21.31), lesion at the coronary anastomosis (3.01, 95% CI 1.19 to 7.69), high diameter stenosis after stent placement (7.21, 95% CI 2.66 to 16.81), placement of long stents (2.73, 95% CI 1.09 to 7.39), and implantation of more than one stent (7.31, 95% CI 2.08 to 19.96) as independent predictors of graft in-stent restenosis. CONCLUSIONS: There appears to be a specific risk factor constellation contributing to the high restenosis rate following stent implantation in venous bypass grafts. Critical consideration of these variables may help identify patients who are poor candidates for stent implantation and who may benefit from a different approach.

[Lipoid pneumonia following attempted suicide by intravenous injection of lamp oil]. / Entwicklung einer lipoiden Pneumonie als Folge einer intravenösen Injektion von Lampenöl in suizidaler Absicht.

BACKGROUND: Pneumonic complications after intoxication with mineral oils have been described before in the contents of accidental aspiration and oral ingestion. However, intoxication following an intravenous injection leading to a lipoid pneumonia after an attempted suicide is a rare finding. CASE REPORT: A case report is presented of an attempted suicide by intravenously self-injection of 20 ml lamp oil (liquid paraffin). Immediately after injection the patient suffered from dry coughing which changed in the course of the next hours into a productive cough with white thick mucous sputum accompanied by hemoptysis. Additionally, he developed a mild disseminated intravascular coagulation with a fall of thrombocytes, an INR of 1.6 and a rise of D-dimeres. Under a therapy with hydrocortisone, ascorbic acid, ambroxol, acetylcysteine, heparin, antibiotics and oxygen, the patient improved without the need of mechanical ventilation. Initially seen signs of right heart dilatation diminished 3 days after onset of therapy. Apart from pulmonal manifestation no relevant organ damage was observed. The patient was discharged from the intensive care unit 9 days after intoxication and was submitted to psychiatric therapy. CONCLUSION: Lipoid pneumonia caused by intoxication with a mineral oil is a severe disease, whereas in the presented case a relative bland course of the disease has been seen. The employed therapy in this patient might be encouraging for a comparable treatment of pneumological complications resulting from similar clinical pictures.

Intracoronary administration of dipyridamole prior to percutaneous transluminal coronary angioplasty provides a protective effect exceeding that of ischemic preconditioning.

BACKGROUND: Ischemic preconditioning renders hearts more resistant to the deleterious consequences of ischemia. Adenosine is an important mediator in the induction and maintenance of ischemic preconditioning. Percutaneous transluminal coronary angioplasty (PTCA) allows the investigation of the consequences of ischemia in humans. The severity of myocardial ischemia decreases with subsequent balloon inflations during the course of PTCA. OBJECTIVE: To compare the effect of intracoronary administration of dipyridamole with the effect of consecutive balloon inflations. METHODS: We investigated 30 patients undergoing PTCA of the left anterior descending coronary artery in the setting of stable angina pectoris. Patients were randomly allocated to be administered either 0.5 mg/kg body weight dipyridamole intracoronarily or an equal amount of saline. Patients administered saline served as a control group. All patients were subjected to three consecutive balloon inflations. Severity of myocardial ischemia was assessed in terms of severity of chest pain, electrocardiographic signs of ischemia, and duration of balloon inflation tolerated. RESULTS: Patients administered dipyridamole intracoronarily tolerated significantly longer durations of balloon inflation than did patients in the control group. Severity of anginal pain and extent of electrocardiographic signs of ischemia were significantly lower after intracoronary administration of dipyridamole. The reductions in anginal pain and ST-segment shift caused by intracoronary administration of dipyridamole during the first balloon inflation were even more pronounced than the protection that was afforded by the third balloon inflation for patients in the control group. CONCLUSIONS: Intracoronary administration of dipyridamole prior to PTCA is associated with a significant gain in tolerance of ischemia. The protection afforded by intracoronary administration of dipyridamole is even more pronounced than the effect of ischemic preconditioning.

[Restenosis predictors after stent implantation of venous aortocoronary bypass grafts]. / Restenose-Prädiktoren nach Stent-Implantation aortokoronarvenöser Bypassgefässe.

Follow-up studies after stent implantation of native coronary arteries have reported reduced rates of angiographic restenosis. In contrast, stent implantation in the treatment of obstructive disease of coronary artery bypass grafts is complicated by higher restenosis rates. We sought to determine, if different predictors contribute to the high restenosis rate following stent implantation of coronary artery bypass grafts. We investigated long-term angiographic outcome of 205 stent implantations performed in 177 patients. Multivariate analysis correlated clinical, procedural and angiographic variables with the incidence of angiographic restenosis defined as diameter stenosis > 50% at follow-up. Angiographic restenosis was observed in 34% of lesions treated. Multiple logistic regression analysis defined diabetes mellitus (OR 6.89, CI 2.41-9.69), graft recanalization (OR 2.69, CI 1.08-6.63), lesion at the aortic anastomosis (OR 6.98, CI 2.76-19.25), lesion at the coronary anastomosis (OR 2.95, CI 1.18-7.49), high diameter stenosis after stent placement (OR 7.01, CI 2.64-15.71), placement of long stents (OR 2.78, CI 1.11-7.36) and implantation of more than one stent (OR 7.34, CI 2.08-20.15) as independent predictors of graft in-stent restenosis. Critical consideration of these variables may help to identify patients who are poor candidates for stent implantation and who may benefit from different interventional approaches.

Preconditioning during percutaneous transluminal coronary angioplasty by endogenous and exogenous adenosine.

BACKGROUND: The purpose of this study was to assess whether pharmacologic preconditioning by exogenous or endogenous adenosine prevents the deterioration of hemodynamic function and left ventricular performance during percutaneous transluminal coronary angioplasty (PTCA). Ischemic preconditioning renders the heart more resistant to subsequent ischemia. Adenosine plays a key role in its pathogenesis. Coronary angioplasty is a suitable model for the induction of myocardial ischemia. METHODS AND RESULTS: We investigated 30 patients receiving PTCA of the left anterior descending coronary. Patients were randomly allocated to either dipyridamole, leading to the liberation of endogenous adenosine (0.5 mg/kg body weight, intracoronary), exogenous adenosine (20 mg intracoronary), or an equal amount of saline. Chest pain, tolerated inflation time, and ST-segment shift were registered. Left ventricular hemodynamics, isovolumetric phase indexes, indexes of volume, ejection fraction, and indexes of diastolic dysfunction were analyzed. Patients receiving endogenous or exogenous adenosine tolerated longer balloon inflation times (dipyridamole, 208 +/- 23 seconds; adenosine, 188 +/- 41 seconds; control, 153 +/- 36 seconds; P <.05). Deterioration of left ventricular ejection fraction was less severe after adenosine (72% +/- 5% before PTCA vs 64% +/- 6% during angioplasty; P =.11) and could be prevented by intracoronary dipyridamole (69% +/- 12% before PTCA vs 68% +/- 11% after PTCA; P <. 01) compared with the control group (71% +/- 7% before PTCA vs 60% +/- 7% during angioplasty). CONCLUSIONS: Intracoronary application of exogenous adenosine and liberation of endogenous adenosine increase the tolerance to ischemia and prevent deterioration of left ventricular function during ischemia. These findings can be attributed to ischemic preconditioning. However, endogenous adenosine exceeds the protective effects of exogenous adenosine.

Effect of adjunctive intracoronary adenosine on myocardial ischemia, hemodynamic function and left ventricular performance during percutaneous transluminal coronary angioplasty: clinical access to ischemic preconditioning?

BACKGROUND: Ischemic preconditioning has been defined as a mechanism that renders the heart more resistant to subsequent ischemia. Adenosine plays an important role in the pathogenesis of ischemic preconditioning. OBJECTIVE: To assess whether intracoronary administration of adenosine prevents the deterioration of left ventricular performance and hemodynamic function by allowing adaptation to myocardial ischemia in the setting of percutaneous transluminal coronary angioplasty (PTCA). DESIGN: This was a prospectively randomized doubly blinded trial. METHODS: We investigated 20 patients undergoing PTCA of the left anterior descending coronary artery supplying myocardium with normal left ventricular function in the setting of stable angina pectoris. Patients were randomly allocated to be administered adenosine intracoronarily (20 mg/10 min) or an equal amount of saline, providing a control population. Results of standardized chest pain questionnaires, tolerated inflation times, ST-segment shifts, left ventricular and aortic pressures, isovolumetric phase indexes, and indexes of volume and ejection fraction during the course of PTCA between the two groups were compared. RESULTS: Patients administered adenosine tolerated significantly longer balloon-inflation times (188 +/- 41 versus 153 +/- 36 s; P = 0.03), which were associated with less pronounced signs of ischemia, and exhibited less deterioration of isovolumetric phase indexes during PTCA. Deterioration of left ventricular ejection fraction was slightly less severe with adenosine (72 +/- 5% before PTCA versus 64 +/- 6% during angioplasty) than it was for the control group (71 +/- 7% before PTCA versus 60 +/- 7% during angioplasty; P = 0.11). CONCLUSIONS: Intracoronary application of adenosine prior to coronary angioplasty increases tolerance of ischemia and prevents deterioration of left ventricular hemodynamics during ischemia. One potential explanation of these results is that induction of ischemic preconditioning took place.

Adjunctive intracoronary dipyridamole in the interventional treatment of small coronary arteries: a prospectively randomized trial.

BACKGROUND: Patients undergoing intracoronary stent placement or balloon angioplasty for the treatment of small coronary arteries are at an increased risk of an adverse outcome from a higher incidence of abrupt closure and restenosis. Intracoronary thrombus formation plays a key role in the pathogenesis of abrupt vessel closure and of restenosis. Dipyridamole prevents platelet aggregation by a mechanism that differs from aspirin. The purpose of this study was to investigate the effect of intracoronary dipyridamole on acute complications and restenosis after percutaneous transluminal coronary angioplasty. METHODS: In a prospectively randomized study including 491 dilatations of coronary arteries with a diameter <2.75 mm, additional intracoronary application of dipyridamole was compared with conventional pretreatment consisting of heparin and aspirin. Study end points were defined as incidence of abrupt vessel closure, myocardial infarction, angiographic restenosis, and target vessel revascularization rate. RESULTS: Intracoronary dipyridamole was associated with a significant reduction of abrupt vessel closure (2.8% vs 8.6%; P =.005) and a nonsignificant reduction of myocardial infarction (1.6% vs 4.5%; P =.07) after percutaneous transluminal coronary angioplasty. Net gain 6 months after angioplasty was significantly higher in the dipyridamole group (0.60 +/- 0.35 mm vs 0.42 +/- 0.34 mm; P <.001). However, dipyridamole failed to reduce the incidence of angiographic restenosis (41.6% vs 49.1%; P =.11) and target vessel revascularization rate (20.6% vs 269%; P =.12). CONCLUSIONS: Intracoronary dipyridamole reduces the incidence of adverse cardiovascular events in the first 48 hours after balloon angioplasty of small coronary arteries. Reduction of restenosis rates failed to reach statistical significance. However, a significant increase in net gain was observed. Thus intracoronary application of dipyridamole should be considered in the treatment of small coronary arteries when intracoronary stenting is not appropriate.

Intracoronary dipyridamole reduces the incidence of abrupt vessel closure following PTCA: a prospective randomised trial.

OBJECTIVES: To investigate the effect of intracoronary dipyridamole on the incidence of abrupt vessel closure, myocardial infarction, necessity for bypass grafting, and death following percutaneous transluminal coronary angioplasty (PTCA). PATIENTS: Patients were randomly allocated to receive either conventional pretreatment (heparin 15 000 IU and aspirin 500 mg intravenously) or additional intracoronary dipyridamole (0.5 mg/kg bodyweight). Dipyridamole was administered in 550 PTCA procedures (455 interventions in men, mean (SD) age 59.2 (8.4) years; 74 acute coronary syndromes), while conventional pretreatment was administered in 544 interventions (444 interventions in men 58.3 (7.9) years old; 81 acute coronary syndromes). In 53 interventions bail out stenting was performed for threatened abrupt vessel closure. RESULTS: Intracoronary dipyridamole significantly reduced the incidence of abrupt vessel closure (odds ratio 0.42. 95% confidence interval (CI) 0.22 to 0.79). While abrupt vessel closure occurred in 6.1% of interventions following conventional pretreatment, dipyridamole reduced the incidence to 2.5%. Restricting the analysis to balloon angioplasty, this reduction was observed in patients with stable angina (odds ratio 0.49, 95% CI 0.23 to 0.96) as well as in those with acute coronary syndromes (odds ratio 0.29, 95% CI 0.09 to 0.87). Reduction of secondary end points in the dipyridamole treated patients failed to reach significance in the PTCA group. CONCLUSIONS: Intracoronary dipyridamole before PTCA reduces the incidence of abrupt vessel closure following PTCA for stable angina and acute coronary syndromes.

[Interventional catheter treatment of bypass graft stenosis: comparison of intracoronary stent implantation and balloon angioplasty]. / Katheterinterventionelle Therapie stenosierter Bypassgefässe. Vergleich zwischen intrakoronarer Stent-Implantation und Ballonangioplastie.

BACKGROUND AND OBJECTIVE: Balloon angioplasty of a stenosed bypass graft has a much higher risk of recurrent stenosis than dilatation of a stenosed native coronary artery. Intracoronary stent implantation has established itself as the better treatment of native coronary artery stenosis than conventional balloon angioplasty. However, there is still uncertainty whether intracoronary stent implantation in stenosed bypass vessels gives better long-term results than conventional balloon angioplasty. PATIENTS AND METHODS: Results were retrospectively analyzed of unrandomized 224 primarily successful interventions--122 balloon dilatations and 102 stent implantations--performed between January 1996 and June 1998 on stenosed coronary bypass grafts, re-examined by coronary angiography an average of 6 months later. All but 11 patients were on combined aspirin and ticlopidine antiplatelet aggregation treatment. RESULTS: There was a significantly lower 6-month restenosis rate (30.4%) after stent implantation than after balloon dilatation (51.6%). The re-intervention rate was also significantly lower after stent implantation. CONCLUSION: These data suggest that stent implantation of stenosed coronary bypass grafts under cover of platelet-aggregation inhibition with aspirin and ticlopidine provides a lower restenosis and thus higher revascularization rate than conventional balloon dilatation.

[Clinical course and complications of meningococcal septicemia]. / Klinischer Verlauf und Komplikationen der Meningokokkensepsis.

BACKGROUND: Meningococcal septicemia is still associated with high mortality with most deaths occurring within the first 24 hours. CASE REPORT: We report on 3 patients with severe meningiococcemia. All patients had an aprupt onset of clinical illness with fever and unspecific prodomi like arthralgias, myalgias and abdominal pain. On admission all patients had severe prostration, hypotension and tachycardia. Two patients presented purpuric rash and petechiae, meningitis was found in only 1 patient. Gram-negative diplococci were demonstrated in spinal fluid primarily in 2 patients, in all patients meningococcae could be cultured in serial blood specimens. Because of severe cardiorespiratory distress all patients required mechanical ventilation and catecholamine support within 24 hours of diagnosis. Complications of meningococcemia demonstrated by these patients were coagulopathy, meningitis, myocarditis with alterations of echocardiographic and ECG records and elevations of CK levels and surgical relevant peripheral gangrene. Antibiotic therapy was initiated with penicillin on the day of admission, which resulted in stabilisation and recuperation in all patients. CONCLUSIONS: In patients with aprupt onset of acute illness, which include fever and sudden petechial rash, severe meningococcal septicemia has to be taken in consideration without clinical signs of meningitis. The prompt diagnosis, the use of parenteral antiobiotics in suspected meningococcal disease as well as the management of meningococcemia and its complications in intensive care units is crucial for the prognosis of the individual patient.

Congenital asplenia detected in a 60 year old patient with septicemia.

A 60 year-old female who had never been seriously ill, was brought to the emergency ward after she had been found somnolent at home. She developed renal failure, meningitis, respiratory distress and disseminated intravascular coagulation. Overwhelming septicemia was evident, and streptococcus pneumoniae was isolated from blood and cerebrospinal fluid. Surprisingly, peripheral blood smears showed numerous Howell-Jolly-bodies, indicating severe impairment of splenic function. On abdominal ultrasound, CT-scan, and scintigraphy no spleen could be detected. There was no history of abdominal surgery. Apparently, congenital asplenia, which was not noticed until the age of 60, was responsible for the patient's life-threatening septicemia. We suggest that, in cases of severe septicemia, the examination of a blood smear is useful to detect functional (or congenital) asplenia.