Early hemodynamic changes after transcatheter aortic valve implantation in patients with severe aortic stenosis measured by invasive pressure volume loop analysis.

Replacement of a stenotic aortic valve reduces immediately the ventricular to aortic gradient and is expected to improve diastolic and systolic left ventricular function over the long term. However, the hemodynamic changes immediately after valve implantation are so far poorly understood. Within this pilot study, we performed an invasive pressure volume loop analysis to describe the early hemodynamic changes after transcatheter aortic valve implantation (TAVI) with self-expandable prostheses. Invasive left ventricular pressure volume loop analysis was performed in 8 patients with aortic stenosis (mean 81.3 years) prior and immediately after transfemoral TAVI with a self-expandable valve system (St. Jude Medical Portico Valve). Parameters for global hemodynamics, afterload, contractility and the interaction of the cardiovascular system were analyzed. Left ventricular ejection fraction, (53.9% vs. 44.8%, p = 0.018), preload recruitable stroke work (68.5 vs. 44.8 mmHg, p = 0.012) and end-systolic elastance (3.55 vs. 2.17, p = 0.036) both marker for myocardial contractility declined significantly compared to baseline. As sign of impaired diastolic function, TAU, a preload-independent measure of isovolumic relaxation (37.3 vs. 41.8 ms, p = 0.018) and end-diastolic pressure (13.1 vs. 16.4 mmHg, p = 0.015) raised after valve implantation. Contrarily, a smaller ratio of end-systolic to arterial elastance (ventricular-arterial coupling) indicates an improvement of global cardiovascular energy efficiency (1.40 vs. 0.97 p = 0.036). Arterial elastance had a strong correlation with the number of conducted rapid ventricular pacings (Pearson correlation coefficient, r = 0.772, p = 0.025). Invasive left ventricular pressure volume loop analysis revealed impaired systolic and diastolic function in the early phase after TAVI with self-expandable valve for the treatment of severe aortic stenosis. Contrarily, we found indications for early improvement of global cardiovascular energy efficiency.

Post-myocardial infarction heart failure dysregulates the bone vascular niche.

The regulation of bone vasculature by chronic diseases, such as heart failure is unknown. Here, we describe the effects of myocardial infarction and post-infarction heart failure on the bone vascular cell composition. We demonstrate an age-independent loss of type H endothelium in heart failure after myocardial infarction in both mice and humans. Using single-cell RNA sequencing, we delineate the transcriptional heterogeneity of human bone marrow endothelium, showing increased expression of inflammatory genes, including IL1B and MYC, in ischemic heart failure. Endothelial-specific overexpression of MYC was sufficient to induce type H bone endothelial cells, whereas inhibition of NLRP3-dependent IL-1ß production partially prevented the post-myocardial infarction loss of type H vasculature in mice. These results provide a rationale for using anti-inflammatory therapies to prevent or reverse the deterioration of bone vascular function in ischemic heart disease.

Aortic valve replacement in patients with preexisting liver disease: Transfemoral approach with favorable survival.

INTRODUCTION: The treatment of aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), but the experience in patients with liver disease is limited. To address this open question, we report the outcome of patients with liver disease undergoing surgical aortic valve replacement (SAVR), transapical (TA), and transfemoral (TF) TAVR. METHODS AND RESULTS: Between January 2004 and August 2016, 4,394 patients received aortic valve replacement at our institution. We identified 85 patients (mean follow-up 504 ± 733 days, age 73.4 ± 9.2 years, 44.7% female) with preexisting liver disease (median model of end-stage liver disease score 11, MELD-Na), who underwent TF-TAVR (n = 30), TA-TAVR (n = 13), or SAVR (n = 42). Baseline Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) and of Mortality and Morbidity (STS-PROMM) were the lowest in SAVR patients (related to TF- and TA-TAVR, both p < 0.01). Operative mortality (18.8%) was high, but no procedure showed superior short-term outcome. Need for renal replacement therapy (31.5% vs. 10.3%, p = 0.046) and reoperation occurred more frequently after SAVR than after TF-TAVR (26.6% vs. 6.7%, p = 0.021). Moreover, TF-TAVR patients had superior long-term survival compared to SAVR (log-rank test p = 0.048 and Cox regression adjusted for MELD and STS-PROM, p = 0.01, HR 0.25, CI95 0.09-0.71). Baseline MELD-Na (p = 0.013) and STS PROMM (p = 0.01) were predictors for operative mortality (ROC-analysis). CONCLUSIONS: Our results indicate increased perioperative risks for patients with liver disease undergoing AVR, but favorable long-term survival after TF-TAVR compared to SAVR. For baseline risk, stratification in patients with liver disease undergoing AVR, MELD-Na and STS-PROMM are valuable predictors.

Cryoballoon versus radiofrequency ablation for paroxysmal atrial fibrillation: a meta-analysis of randomized controlled trials.

OBJECTIVE: The aim of this study was to evaluate the clinical efficacy and safety outcomes of the treatment with cryoballoon (CB) compared to the treatment with traditional irrigated radiofrequency ablation (RF) for pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (pAF) and refractory to antiarrhythmic drug therapy (AAD). DESIGN: We conducted a systemic review to find and include more than two randomized controlled trials (RCTs) with at least 20 patients in each of the CB and RF groups. Thereafter, we performed a meta-analysis to compare the treatment with CB and RF in primary outcomes including 1 year free from AF, complications and re-ablation procedures. Additionally, we evaluated procedure time and fluoroscopy duration in both groups. Risk of bias in the individual studies and across studies was assessed using Cochrane methods. DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted study data and assessed risk of bias. Primary outcome data were extracted from the time point 1 year after the procedure. The random-effects model was used to calculate the odds ratio with 95% confidence interval. DATA SOURCES: Data sources utilized were PubMed and CENTRAL databases up to 16 June 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies were RCTs in adults with pAF and refractory to AAD in which CB therapy, including 1st and 2nd generation CB, was compared to the traditional irrigated RF therapy. Clinical outcomes assessed in each RCT were 1 year AF-free survival, complication rates, re-ablations, fluoroscopy time and procedure time. RESULTS: The systematic review identified four randomized controlled trials that reported on comparative clinical outcomes involving 1284 patients. Our meta-analysis demonstrated that CB ablation had a non-significant higher success rate than RF therapy (OR 1.13; 95% CI 0.72-1.77). However, our study showed a relatively higher rate of complications in the CB group (OR 1.20; 95% CI 0.58-2.52). Furthermore, CB treatment was associated with a non-significant, shorter procedure time and marginally prolonged fluoroscopy time in comparison to RF treatment. CONCLUSION: Our systemic review and meta-analysis revealed further evidence that cryoballoon ablation is an equally effective alternative procedure to the standard radiofrequency treatment with a slightly, non-significant higher freedom from AF 1 year after the ablation and a shorter procedure time.

Changes in the prevalence, treatment and control of hypertension in Germany? A clinical-epidemiological study of 50.000 primary care patients.

INTRODUCTION: Medical societies have developed guidelines for the detection, treatment and control of hypertension (HTN). Our analysis assessed the extent to which such guidelines were implemented in Germany in 2003 and 2001. METHODS: Using standardized clinical diagnostic and treatment appraisal forms, blood pressure levels and patient questionnaires for 55,518 participants from the cross-sectional Targets and Essential Data for Commitment of Treatment (DETECT) study (2003) were analyzed. Physician's diagnosis of hypertension (HTN(doc)) was defined as coding hypertension in the clinical appraisal questionnaire. Alternative definitions used were physician's diagnosis or the patient's self-reported diagnosis of hypertension (HTN(doc,pat)), physician's or patient's self-reported diagnosis or a BP measurement with a systolic BP ≥ 140 mmHg and/or a diastolic BP ≥ 90 (HTN(doc,pat,bp)) and diagnosis according to the National Health and Nutrition Examination Survey (HTN(NHANES)). The results were compared with the similar German HYDRA study to examine whether changes had occurred in diagnosis, treatment and adequate blood pressure control (BP below 140/90 mmHg) since 2001. Factors associated with pharmacotherapy and control were determined. RESULTS: The overall prevalence rate for hypertension was 35.5% according to HTN(doc) and 56.0% according to NHANES criteria. Among those defined by NHANES criteria, treatment and control rates were 56.0% and 20.3% in 2003, and these rates had improved from 55.3% and 18.0% in 2001. Significant predictors of receiving antihypertensive medication were: increasing age, female sex, obesity, previous myocardial infarction and the prevalence of comorbid conditions such as coronary heart disease (CHD), hyperlipidemia and diabetes mellitus (DM). Significant positive predictors of adequate blood pressure control were CHD and antihypertensive medication. Inadequate control was associated with increasing age, male sex and obesity. CONCLUSIONS: Rates of treated and controlled hypertension according to NHANES criteria in DETECT remained low between 2001 and 2003, although there was some minor improvement.

[Cardiovascular risk assessment by primary-care physicians in Germany and its lack of agreement with the Established Risk Scores (DETECT)]. / Kardiovaskuläre Risikoabschätzung in der Hausarztpraxis (DETECT). Wie gut stimmt die Hausarzteinschätzung mit den etablierten Risikoscores überein?

BACKGROUND: The concordance of several cardiovascular risk scores (PROCAM Score, Framingham Score and ESC Score) and its agreement with the treating physicians' risk assessment is unclear. METHODS: For 8,957 nationally representative primary-care patients without known cardiovascular disease (age 40-65 years), the 10-year risk for experiencing a myocardial infarction or coronary death was determined by using various established risk scores in addition to risk prediction by the treating primary-care physician. RESULTS: In this sample, the mean 10-year coronary morbidity risk was estimated by PROCAM to be 4.9% and 10.1% by the Framingham Score. The mean 10-year cardiovascular mortality risk, estimated by the ESC Score, was 2.9%. According to the risk assessment of the primary-care physicians only 2.7% of the patients were assigned to this group. The number of patients assigned to high, medium and low risk differed substantially. Applying the Framingham Score, 22.6% of all patients were assigned to the high-risk group. Concordance in cardiovascular risk categorization between all three scores was present in only 34.0% of all cases. In 5.9% of the patients the three risk scores yielded completely different risk estimations. Only approximately 8% of the patients assigned to the high-risk group according to the different scores were also recognized as high-risk patients by the primary-care physicians. For approximately 48% of these patients the physician allocated a medium risk and for 41-46% even only a low risk. CONCLUSION: The substantial level of disagreement between the different scores as well as of the scores with the prediction of the treating physicians underlines that risk stratification with the established scores evidently plays no significant role in routine care at this point. Which of the score predictions should be considered to be most sensitive and specific will be examined now prospectively using the 5-year prospective data of the DETECT study.