Not to Rush-Laboratory Parameters and Procedural Complications in Patients Undergoing Left Atrial Appendage Closure.

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3−5) and the median HAS-BLED score was 3 (2−4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65−0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5−68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate.

Left Atrial Appendage Morphology and Left Atrial Wall Thickness Are Associated with Cardio-Embolic Stroke.

BACKGROUND: New markers for stroke risk stratification in patients with atrial fibrillation (AF) are on demand. Hence, we aimed to investigate the association of left atrial appendage (LAA) and left atrium (LA) morphological parameters in patients with cardio-embolic (CE) stroke due to AF in comparison to controls without stroke. METHODS: A retrospective analysis of cardiac computed tomography angiography (CTA) examinations performed between 2006 and 2017 for clinical indications in 158 patients (median age 65 (54-73) years, 48.7% females) was conducted: 56 patients with CE stroke were compared to 102 controls not differing in gender, body mass index (BMI) and CHA2DS2-VASc score. RESULTS: On multivariable regression analysis adjusted for CHA2DS2-VASc score and LA diameter CE stroke was independently associated with the following parameters: windsock LAA type (OR 2.55; CI: 1.04-6.26, p = 0.041), a greater lobe number (OR 1.54; CI: 1.13-2.10, p = 0.006), a greater LAA ostium area (OR 1.88; CI: 1.38-2.55, p < 0.001) and a greater left atrium wall thickness (LAWT) in the middle and right part, measured along the anterior LA wall in the axial plane (respectively, OR 1.94; CI: 1.26-3.0, p = 0.003 and OR 1.57; CI: 1.07-2.31, p = 0.021). CONCLUSIONS: The windsock LAA type, a greater LAA lobe number, a larger LAA ostium and a greater LAWT are associated with CE stroke. These CTA parameters could improve risk stratification for thromboembolic stroke.

Indications and Outcome in Patients Undergoing Left Atrial Appendage Closure-The Austrian LAAC Registry.

BACKGROUND: Complete real-world data on the indications and outcomes of left atrial appendage closure (LAAC) outside of clinical trials are rare. In this study, we stratified patients undergoing LAAC by indication groups. METHODS: This analysis of the national multicentre Austrian LAAC Registry comprised all patients that underwent LAAC up until 2018 at the currently active centres in Austria. The baseline characteristics, procedural details and outcomes between the following indication groups were compared: bleeding as an indication for LAAC ("bleeding" group) vs. thromboembolism despite oral anticoagulation (OAC; "thromboembolism" group) vs. an intolerance to OAC for reasons other than the above ("other" group). RESULTS: The analysis included 186 patients, with 59.7% in the "bleeding" group, 8.1% in the "thromboembolism" group and 32.2% in the "other" group. The CHADS2 score was the highest in the "thromboembolism" group and the HAS-BLED score was the highest in the "bleeding" group. The procedural outcomes were similar between groups (implantation success, 97.3%), with major complications occurring in 7.0% of patients. One-year survival free from stroke, bleeding or LAAC-associated hospitalisation was 83.9%, 90.0% and 81.4% in the "bleeding", "thromboembolism" and "other" groups, respectively (p = 0.891). CONCLUSIONS: In routine clinical practice, LAAC was used in a heterogeneous patient population with atrial fibrillation (AF) and contraindication, inefficacy or intolerance to OAC. The long-term outcome was favourable in all groups.

Open surgical retrieval of an embolized PFO occluder system.

Device migration after intervention for persistent foramen ovale occlusion is a rare complication. In case of failure of endovascular device retrieval, open surgical removal is indicated, safe, and reliable.

Adult patent ductus arteriosus : An unusual cause of heart failure in an octogenarian female.

Patent ductus arteriosus (PDA) is the third most common congenital abnormality in which the arterial duct, which normally closes spontaneously after birth within 24-48 h in full-term infants, remains permanently open. Breathlessness is very common in elderly patients and can be caused by several comorbidities, mostly cardiac and pulmonary diseases. PDA as a cause of heart failure in this patient population is very rare and diagnosis depends on high clinical awareness. Here we present a case diagnosed with multimodality imaging including 3­dimensional (3D) transthoracic and transesophageal echocardiography and 3D-volume rendering technique (VRT) computed tomography.

Fate of cellulose nanocrystal aerosols deposited on the lung cell surface in vitro.

When considering the inhalation of high-aspect ratio nanoparticles (HARN), the characterization of their specific interaction with lung cells is of fundamental importance to help categorize their potential hazard. The aim of the present study was to assess the interaction of cellulose nanocrystals (CNCs) with a multicellular in vitro model of the epithelial airway barrier following realistic aerosol exposure. Rhodamine-labeled CNCs isolated from cotton (c-CNCs, 237 ± 118 × 29 ± 13 nm) and tunicate (t-CNCs, 2244 ± 1687 × 30 ± 8 nm) were found to display different uptake behaviors due to their length, although also dependent upon the applied concentration, when visualized by laser scanning microscopy. Interestingly, the longer t-CNCs were found to exhibit a lower clearance by the lung cell model compared to the shorter c-CNCs. This difference can be attributed to stronger fiber-fiber interactions between the t-CNCs. In conclusion, nanofiber length and concentration has a significant influence on their interaction with lung cells in vitro.

An in vitro testing strategy towards mimicking the inhalation of high aspect ratio nanoparticles.

BACKGROUND: The challenge remains to reliably mimic human exposure to high aspect ratio nanoparticles (HARN) via inhalation. Sophisticated, multi-cellular in vitro models are a particular advantageous solution to this issue, especially when considering the need to provide realistic and efficient alternatives to invasive animal experimentation for HARN hazard assessment. By incorporating a systematic test-bed of material characterisation techniques, a specific air-liquid cell exposure system with real-time monitoring of the cell-delivered HARN dose in addition to key biochemical endpoints, here we demonstrate a successful approach towards investigation of the hazard of HARN aerosols in vitro. METHODS: Cellulose nanocrystals (CNCs) derived from cotton and tunicates, with differing aspect ratios (~9 and ~80), were employed as model HARN samples. Specifically, well-dispersed and characterised CNC suspensions were aerosolised using an "Air Liquid Interface Cell Exposure System" (ALICE) at realistic, cell-delivered concentrations ranging from 0.14 to 1.57 µg/cm2. The biological impact (cytotoxicity, oxidative stress levels and pro-inflammatory effects) of each HARN sample was then assessed using a 3D multi-cellular in vitro model of the human epithelial airway barrier at the air liquid interface (ALI) 24 hours post-exposure. Additionally, the testing strategy was validated using both crystalline quartz (DQ12) as a positive particulate control in the ALICE system and long fibre amosite asbestos (LFA) to confirm the susceptibility of the in vitro model to a fibrous insult. RESULTS: A rapid (≤ 4 min), controlled nebulisation of CNC suspensions enabled a dose-controlled and spatially homogeneous CNC deposition onto cells cultured under ALI conditions. Real-time monitoring of the cell-delivered CNC dose with a quartz crystal microbalance was accomplished. Independent of CNC aspect ratio, no significant cytotoxicity (p>0.05), induction of oxidative stress, or (pro)-inflammatory responses were observed up to the highest concentration of 1.57 µg/cm2. Both DQ12 and LFA elicited a significant (p<0.05) pro-inflammatory response at sub-lethal concentrations in vitro. CONCLUSION: In summary, whilst the present study highlights the benign nature of CNCs, it is the advanced technological and mechanistic approach presented that allows for a state of the art testing strategy to realistically and efficiently determine the in vitro hazard concerning inhalation exposure of HARN.

Relative amplitude index: a new tool for hemodynamic evaluation of periprosthetic regurgitation after transcatheter valve implantation.

OBJECTIVE: The impact of paravalvular aortic regurgitation (PAR) on hemodynamic performance after transcatheter aortic valve implantation (TAVI) remains disputable. Common parameters such as the diastolic blood pressure or the blood pressure amplitude do not provide reproducible results. The aim of our study was to evaluate the impact of PAR on hemodynamics and outcome using the relative amplitude index (RAI). METHODS: PAR was prospectively evaluated by echocardiography before discharge in 110 patients. The RAI was calculated according to the formula: RAI = [(Post-TAVI BP amplitude)/(Post-TAVI SBP) - (Pre-TAVI BP amplitude)/(Pre-TAVI SBP)] × 100%, where BP is blood pressure and SBP is systolic blood pressure. Correlations of increased RAI with perioperative outcome were investigated and factors influencing mortality were isolated. RESULTS: The incidence of moderate and severe PAR after TAVI was 9% and 1%, respectively. Diastolic pressure or post-TAVI amplitude did not correlate to perioperative outcome. RAI increased from 2 when PAR was <2+ to 7 when PAR was ≥2+ (P = .006). A cut-off value of RAI ≥14 was associated with increased perioperative mortality (29 vs 5%; P = .013) and acute renal injury requiring dialysis (71 vs 18%; P = .001). RAI ≥14 was also associated with higher follow-up mortality at 1 year (57 vs 16%; P = .007). RAI ≥14 (odds ratio [OR], 3.390; 95% confidence interval [CI], 1.6-7.194; P = .00146), PAR ≥2+ (OR, 4.717; 95% CI, 1.828-12.195; P = .00135), and perioperative renal replacement therapy (OR, 12.820; 95% CI, 5.181-31.250; P = .00031) were found to be independent predictors of mortality at 1 year. CONCLUSIONS: The RAI is a useful tool to predict perioperative and 1-year outcome in patients with PAR after TAVI.

Bionanocomposites: differential effects of cellulose nanocrystals on protein diblock copolymers.

We investigate the effects of mixing a colloidal suspension of tunicate-derived cellulose nanocrystals (t-CNCs) with aqueous colloidal suspensions of two protein diblock copolymers, EC and CE, which bear two different self-assembling domains (SADs) derived from elastin (E) and the coiled-coil region of cartilage oligomeric matrix protein (C). The resulting aqueous mixtures reveal improved mechanical integrity for the CE+t-CNC mixture, which exhibits an elastic gel network. This is in contrast to EC+t-CNC, which does not form a gel, indicating that block orientation influences the ability to interact with t-CNCs. Surface analysis and interfacial characterization indicate that the differential mechanical properties of the two samples are due to the prevalent display of the E domain by CE, which interacts more with t-CNCs leading to a stronger network with t-CNCs. On the other hand, EC, which is predominantly C-rich on its surface, does not interact as much with t-CNCs. This suggests that the surface characteristics of the protein polymers, due to folding and self-assembly, are important factors for the interactions with t-CNCs, and a significant influence on the overall mechanical properties. These results have interesting implications for the understanding of cellulose hydrophobic interactions, natural biomaterials and the development of artificially assembled bionanocomposites.

Prediction of paravalvular regurgitation after transcatheter aortic valve implantation by computed tomography: value of aortic valve and annular calcification.

BACKGROUND: The purpose of this study was to quantify and characterize aortic valve leaflet and aortic annular calcification with computed tomography angiography (CTA) and to define whether they predict paravalvular regurgitation (PAR) after transcatheter aortic valve implantation. METHODS: In all, 94 patients (aged 83.6 years) with severe aortic stenosis underwent CTA. Annular calcification was measured in two planes and defined as "protruding" (depth greater than length), "round," or "adherent" (length less than depth) for the right, left, and noncoronary annulus. Leaflet calcification severity and asymmetry were scored. Transthoracic echocardiography graduation of PAR severity was performed after the procedure (0.5 scale). RESULTS: Thirty-two percent of patients had no or trivial PAR (grade less than 1) and 68% had mild to severe PAR (≥ 1 [mild 45.7%, moderate 20.2%, moderate to severe 2.1%]). The size of annular calcium was higher in patients with moderate to severe PAR greater than 1 (p = 0.015, p = 0.007, and p = 0.004) and predictive (c = 0.67, 0.71, and 0.711) for noncoronary, left, and total annular calcium size, respectively. Increasing PAR severity was correlated with increasing total calcium size (r = 0.422, p < 0.001). Protruding annular calcification greater than 4 mm (p = 0.02) was more frequently found in moderate to severe PAR greater than 1, and predictive (c = 0.7). Adherent calcium greater than 4 mm did not predict PAR greater than 1 and PAR of 1 or less. There was no association of leaflet calcium severity and asymmetry with PAR severity. CONCLUSIONS: Protruding annular calcium greater than 4 mm predicts moderate to severe PAR after transcatheter aortic valve implantation. Increasing annular calcium size is another predictor, whereas adherent calcium has a "sealing" effect.

Benefits of high-pitch 128-slice dual-source computed tomography for planning of transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for high-risk and inoperable patients. Advanced multimodality imaging, including computed tomography (CT), plays a key role for optimized planning of TAVI. METHODS: Forty-nine patients (25 women; age, 82.3±8.8 year) with severe aortic stenosis scheduled for TAVI were examined with 128-slice high-pitch dual-source prospective aortoiliac CT angiography (CTA). The 3-coronary-sinus-alignment (3-CSA) plane, comprising left and right anterior oblique and craniocaudal projection, was defined from three-dimensional volume-rendered technique data sets and compared with the intraoperative angiographic plane (deployment plane) used for device implantation. A tolerance level of ±5-degree deviation was acceptable. Volume of intraoperative iodine contrast agent was compared before and after the implementation of the 3-CSA plane estimation by CT. RESULTS: All 49 patients underwent TAVI, during which 6 CoreValves (Medtronic, Minneapolis, MN) and 43 Sapien valves (Edwards Lifesciences, Irvine, CA) were successfully implanted using transapical (n=29), transfemoral (n=17), and transaxillary access (n=4). No severe complications occurred. In 47 patients (96%), CTA correctly predicted the 3-CSA plane used for device implantation. Mean left anterior oblique by CTA was 5.3±6.5 degrees and craniocaudal was -1.3±10.1 degrees. Mean left anterior oblique deviation between CTA and the intraoperative projection was 2.1±2.7 degrees and craniocaudal was 1.7±3.0 degrees. Ostium heights of the right and left coronary arteries were 12±1.9 and 12.9±3.3 mm. No over-stenting occurred in left coronary artery ostia of 8 mm or more. Contrast volume was reduced from 81.8±25.6 to 59.4±40.2 mL (p=0.05) when using 3-CSA plane estimation by CT for final prosthesis implantation plane. CONCLUSIONS: Aortoiliac high-pitch 128-slice dual-source CT contributes to TAVI planning, including reliable prediction of the 3-CSA valve deployment plane, which saves contrast volume during the procedure and may facilitate correct valve placement.

Detection of bioprosthetic valve infection by image fusion of (18)fluorodeoxyglucose-positron emission tomography and computed tomography.

A 63-year old male with prior bioprosthetic mitral valve replacement and coronary artery bypass graft surgery presented with dyspnea. C-reactive protein and white blood cells were elevated and serial blood cultures were negative. Transesophageal echocardiography showed a paravalvular leak and a thickened anterior leaflet of unclear either infective or degenerative origin. For differential diagnosis, cardiac 128-dual source computed tomography (CT) was performed. The CT image showed a thickened anterior leaflet and further revealed that the paravalvular leak was draining into a large wall thickened pseudoaneurysm with dense tissue adjacent suggestive for an abscess. Therefore, (18)fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) was appended and fused with the CT images. There was no tracer-uptake surrounding the leak excluding an abscess. However, an increased (18)FDG-tracer uptake at the thickened anterior leaflet indicated active inflammation. During the subsequent cardiac surgery, vegetations were identified on the anterior cusp of the bioprosthetic valve. Intraoperative biopsy was taken and the cell culture was positive for Staphylococcus aureus. The pseudoaneurysm was repaired and the valve was replaced with a bioprosthesis. The patient was discharged uneventfully from hospital on day 12 and antibiotic treatment was continued for 4 weeks. In conclusion, our case indicates that (18)FDG-PET with cardiac CT image fusion may be a useful tool in patients with unclear focus of inflammation and possible bioprosthesis infection.

Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography.

RATIONALE AND OBJECTIVES: Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS: Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS: A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION: Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.

Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings.

OBJECTIVES: The aim of this study was to assess the value of multislice computed tomography (CT) for the assessment of valvular abnormalities in patients with infective endocarditis (IE) in comparison with transesophageal echocardiography (TEE) and intraoperative findings. BACKGROUND: Multislice CT has recently shown promising data regarding valvular imaging in a 4-dimensional fashion. METHODS: Thirty-seven consecutive patients with clinically suspected IE were examined with TEE and 64-slice CT or dual-source CT. Twenty-nine patients had definite IE and underwent surgery. RESULTS: The diagnostic performance of CT for the detection of evident valvular abnormalities for IE compared with TEE was: sensitivity 97%, specificity 88%, positive predictive value (PPV) 97%, and negative predictive value (NPV) 88% on a per-patient basis (n = 37; excellent intermodality agreement kappa = 0.84). CT correctly identified 26 of 27 (96%) patients with valvular vegetations and 9 of 9 (100%) patients with abscesses/pseudoaneurysms compared with the intraoperative specimen. On a per-valve-based analysis, diagnostic accuracy for the detection of vegetations and abscesses/pseudoaneurysms compared with surgery was: sensitivity 96%, specificity 97%, PPV 96%, NPV 97%, and sensitivity 100%, specificity 100%, PPV 100%, NPV 100%, respectively, without significant differences as compared with TEE. Vegetation size measurements by CT correlated (r = 0.95; p <0.001) with TEE (mean 7.6 +/- 5.6 mm). The mobility of vegetations was accurately diagnosed in 21 of 22 (96%) patients with CT, but all of 4 leaflet perforations (

Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome.

BACKGROUND: Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes. METHODS: Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient. RESULTS: No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962). CONCLUSIONS: Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.

Mitral valve repair provides improved outcome over replacement in active infective endocarditis.

OBJECTIVES: Mitral repair in active infective endocarditis still remains controversial. Several studies demonstrate the feasibility of mitral repair in infective endocarditis; however, superiority of repair has never been shown. The aim of the investigation was to compare valve repair and valve replacement in respect to the extent of destruction and to analyze survival, recurrent endocarditis, and reoperation (event-free survival). METHODS: Sixty-eight consecutive patients underwent surgical intervention for mitral endocarditis. Thirty-four (50%) patients had valve repair, and 34 (50%) patients had valve replacement. Leaflet destruction involving at least one mitral leaflet was present in 15 (44.1%) patients of the repair group and 11 (32.4%) patients of the replacement group. Repair of the mitral annulus with pericardium was performed in 4 (11.8%) patients in the repair group and 3 (8.8%) patients in the replacement group. Patients in both groups were similar concerning the progression of valvular destructions and comorbidities. RESULTS: Hospital mortality was 11.8% (8 patients). No significant differences were found in all baseline parameters, with the exception of a higher incidence of previous septic embolism and sepsis in the repair group. Actuarial event-free survival at 1 year was 88.2% in the repair group compared with 67.7% in the replacement group, and 5-year event-free survival was 80.4% in the repair group and 54.6% in the replacement group (P = .015). Mitral valve repair remained the superior treatment regarding event-free survival in the multivariate analysis (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .02). CONCLUSIONS: Mitral valve repair offers excellent early and late results and is the preferable treatment option in the surgical therapy of native infective endocarditis.