Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR)2 registry.

BACKGROUND: Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. AIMS: This study aimed to analyze the use of coronary physiology in clinical practice. METHODS: Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. RESULTS: F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%). CONCLUSIONS: In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.

Impact of the COVID-19 pandemic on cardiovascular mortality and catherization activity during the lockdown in central Germany: an observational study.

AIMS: During the COVID-19 pandemic, hospital admissions for cardiac care have declined. However, effects on mortality are unclear. Thus, we sought to evaluate the impact of the lockdown period in central Germany on overall and cardiovascular deaths. Simultaneously we looked at catheterization activities in the same region. METHODS AND RESULTS: Data from 22 of 24 public health-authorities in central Germany were aggregated during the pandemic related lockdown period and compared to the same time period in 2019. Information on the total number of deaths and causes of death, including cardiovascular mortality, were collected. Additionally, we compared rates of hospitalization (n = 5178) for chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and out of hospital cardiac arrest (OHCA) in 26 hospitals in this area. Data on 5,984 deaths occurring between March 23, 2020 and April 26, 2020 were evaluated. In comparison to the reference non-pandemic period in 2019 (deaths: n = 5832), there was a non-significant increase in all-cause mortality of 2.6% [incidence rate ratio (IRR) 1.03, 95% confidence interval (CI) 0.99-1.06; p = 0.16]. Cardiovascular and cardiac mortality increased significantly by 7.6% (IRR 1.08, 95%-CI 1.01-1.14; p = 0.02) and by 11.8% (IRR 1.12, 95%-CI 1.05-1.19; p < 0.001), respectively. During the same period, our data revealed a drop in cardiac catherization procedures. CONCLUSION: During the COVID-19-related lockdown a significant increase in cardiovascular mortality was observed in central Germany, whereas catherization activities were reduced. The mechanisms underlying both of these observations should be investigated further in order to better understand the effects of a pandemic-related lockdown and social-distancing restrictions on cardiovascular care and mortality.

Capsule Endoscopy in Patients with Cardiac Pacemakers and Implantable Cardioverter Defibrillators: (Re)evaluation of the Current State in Germany, Austria, and Switzerland 2010.

Background and Aims. The study was a repeated evaluation of the experience of capsule endoscopy (CE) in patients with cardiac pacemaker or implantable cardioverter defibrillator (ICD). Patients and Methods. A standardized questionnaire was sent by the manufactors Given Imaging and Olympus to all centers in Germany, Austria, and Switzerland providing capsule endoscopy service. The questionnaire covers the number of examined patients, monitoring during CE, check of the electric implants before and after CE, occurrence of arrhythmia, quality of CE video, complications, indication of CE, and type of institution. Results. Overall 580 questionnaires were sent to the users. 26/5% (Germany/Austria + Switzerland) of the questionnaires were sent back anonymously to the authors. 114 centers (82 hospitals, 11 surgeries, 21 without specification) replied. In 58 centers (51%), patients with cardiac pacemaker (n = 300) and ICDs (n = 80) underwent uneventful capsule endoscopy. The predominant indication (patients with CP 97%, patients with ICD 100%) was mid gastrointestinal bleeding. Conclusion. The results of our inquiry show that in spite of formal contraindication CE is increasingly applied in bleeding patients with cardiac pacemakers/ICDs and seems to be safe even in a large cohort.

Capsule endoscopy in patients with cardiac pacemakers, implantable cardioverter defibrillators, and left heart devices: a review of the current literature.

Background and Study Aims. Capsule endoscopy is an established tool for investigation of the small intestine. Because of limited clinical experience in patients with cardiac devices, the Food and Drug Administration and the manufacturer recommended not to use capsule endoscopy in these patients. The vast majority of investigations did not reveal any interference between capsule endoscopy and cardiac devices. Methods. Studies investigating interference between CE and cardiac devices were analysed. For the review we considered studies published in English or German and indexed in Medline, as well as highly relevant abstracts. Results. In vitro and in vivo studies mainly revealed no interference between capsule endoscopy and cardiac devices. Technical data of capsule endoscopy (Given Imaging) reveal that interference with cardiac pacemakers and implantable cardioverter defibrillator is impossible. Telemetry can interfere with CE video. Conclusion. The clinical use of capsule endoscopy (Given Imaging) is unproblematic in patients with cardiac pacemakers.

Capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter-defibrillators - a retrospective multicenter investigation.

BACKGROUND & AIMS: Capsule endoscopy (CE) is an established tool for the investigation of the small intestine. The Food and Drug Administration, Given Imaging and Olympus have not recommended the use of capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators (ICDs). The aim of this retrospective study was to investigate the safety of capsule endoscopy systems (Given Imaging and Olympus) when applied in patients with different types of pacemakers/ICDs in vivo. METHODS: A standardized questionnaire was sent to high volume centers in Germany and in Austria. The questionnaire covered the age and gender of the examined patients, indication of CE, brand and type of CE, brand and model of pacemaker/ICD, check of the devices before and after CE, monitoring during CE, possible interference between CE and cardiac pacemakers/ICDs and possible adverse events during CE. RESULTS: Data from 62 patients were retrieved for this study. Capsules used were Given Imaging (n=58; M2A, M2Aplus, PillCam SB2), Olympus EndoCapsule (n=3), Given PillCam Colon (n=1). The collective included patients with pacemakers/ICDS from seven brands (Biotronik, Medtronic, St. Jude Medical, Guidant, Boston Scientific, Ela Sorin, Vitatron) with a total of 19/8 (pacemaker/ICD) different types. In two patients interference between capsule endoscopy and telemetry (loss of images/gaps in video) was recorded. None of the cardiac pacemakers or ICDs was impaired in function. No clinically evident event was observed in any of these patients. CONCLUSIONS: Clinical use of these CE types is safe in patients with cardiac pacemakers and ICDs. Interference can occur between CE and ECG-telemetry leading to loss of images or impaired quality of video.

Endograft collapse after endovascular treatment for thoracic aortic disease.

Endovascular treatment is an established therapy for thoracic aortic disease. Collapse of the endograft is a potentially fatal complication. We reviewed 16 patients with a thoracic endograft between 2001 and 2006. Medical records of the treated patients were studied. Data collected include age, gender, diagnosis, indication for endoluminal treatment, type of endograft, and time of follow up. All patients (n = 16; mean age, 61 years; range, 21-82 years) underwent computed tomography (CT) for location of the lesion and planning of the intervention. Time of follow-up with CT scan ranged from 1 to 61 months. Indications for endovascular treatment were degenerative aneurysm (n = 7; 44%), aortic dissection (n = 2; 12%), perforated aortic ulcer (n = 4; 25%), and traumatic aortic injury (n = 3; 19%). Three patients suffered from a collapse of the endograft (one patient distal, two patients proximal) between 3 and 8 days after endovascular treatment. These patients were younger (mean age, 37 +/- 25 years vs. 67 +/- 16 years; P < 0.05) and showed more oversizing (proximal, 36 +/- 19.8% vs. 29 +/- 20.7% [P > 0.05]; distal, 45 +/- 23.5% vs. 38 +/- 21.7% [P > 0.05]). Proximal collapse was corrected by placing a bare stent. In conclusion, risk factors for stent-graft collapse are a small lumen of the aorta and a small radius of the aortic arch curvature (young patients), as well as oversizing, which is an important risk factor and is described for different types of endografts and protheses (Gore TAG and Cook Zenith). Dilatation of the collapsed stent-graft is not sufficient. Following therapy implantation of a second stent or surgery is necessary in patients with a proximal endograft collapse. Distal endograft collapse can possibly be treated conservatively under close follow-up.

[75-year old female with progressive idiopathic lung fibrosis]. / 75-jährige Patientin mit progredienter idiopathischer Lungenfibrose.

CASE REPORT: A 75-year old female was admitted to the intensive care unit because of a respiratory insufficiency during a bronchoscopy. Extubation was done rapidly. Two months before, the patient suffering from breast cancer without metastases underwent a radical mastectomy. Thoracic x-ray presented a progressive shadow. Differential diagnoses took into consideration neoplastic, infectious or immunologic causes. The following day the patient suffered from dyspnea. A cardiopulmonary resuscitation was without success. Obduction revealed a honeycomb lung. Histology presented an idiopathic lung fibrosis.

[Coincidence of coronary artery disease and takotsubo cardiomyopathy in a 72-year-old female patient]. / Koinzidenz von koronarer Herzkrankheit und Takotsubo-Kardiomyopathie bei einer 72-jährigen Patientin.

BACKGROUND: Takotsubo cardiomyopathy is characterized by transient left ventricular dysfunction in patients with normal findings on coronary angiography. The simultaneous incidence of coronary vessel disease and takotsubo cardiomyopathy is described. CASE REPORT: A 72-year-old, previously healthy female patient reported about chest pain. Acute emotional and physical stress were denied. Cardiac enzymes and electrocardiogram presented typical findings of myocardial infarction. Coronary angiography revealed a coronary one-vessel disease with occlusion of the second branch of the circumflex branch of the left coronary artery which did not explain the severe reduction of left ventricular function. After 4 months, left ventricular function and electrocardiogram had returned to normal. CONCLUSION: Coronary artery disease does not rule out takotsubo cardiomyopathy.

Comparison of 5 French versus 6 French guiding catheters for transradial coronary intervention: a prospective, randomized study.

We compared 5 versus 6 French (Fr) guiding catheters in coronary intervention using the transradial approach. Smaller guiding catheters may have advantages over larger ones in transradial coronary intervention. However, there is uncertainty about how small is small enough, and when smaller would become too small. Eligible patients were randomized between the 5 and 6 Fr groups before the procedure. The primary endpoint was procedural success. A total of 216 patients were randomized. Procedural success was obtained in 95% of the 6 Fr group versus 90% of the 5 Fr group (p = 0.25). Most of the failures in the 5 Fr group were because of cross-over to the 6 Fr group. Crossover to the 5 Fr group occurred in 1 patient in the 6 Fr group (0.9%; p = 0.05) because of a small radial artery. Transradial intervention using 5 Fr guiding catheters necessitates crossover to a 6 Fr catheter in 6.8% of cases, and offers no clear advantages over the 6 Fr technique.

Transradial approach for coronary angioplasty in the setting of acute myocardial infarction: a dual-center registry.

Although transradial angioplasty has been shown to have no major entry site-related complications, its clinical applicability for balloon angioplasty and stenting in acute myocardial infarction (AMI) is unclear. In order to assess the feasibility, safety, and clinical outcome of transradial access for coronary angioplasty (PTCA) and stenting during AMI, transradial angioplasty for AMI was registered on a prospective database at two European sites (A and B) with experience in the radial approach (RA); 6 Fr catheters with an inner lumen of at least 0.064" and low-profile rapid-exchange balloons were used. Primary success rates and procedural complications of 6 Fr RA were determined and compared to 6 Fr femoral approach (FA) procedures. A total of 1,224 AMI patients entered the registry. Study site A enrolled 185 RA patients (13.6% AMI) and study site B 92 RA patients (63.4%). Patient baseline demographics were similar in both study centers and showed no differences between RA and FA patients, except a more frequent use of abciximab in study site B compared to A. PTCA was successful in > 95% of both RA and FA patients. Total procedural time did not differ between RA and FA patients. Severe access site-related bleeding complications, however, were observed in FA patients only: study site A used closure devices routinely and found 2% severe bleedings; study site B used no closure device for FA patients and observed 7% severe bleedings. In selected patients and in experienced hands, transradial PTCA in AMI has a high success rate, is clinically safe, and could become an attractive alternative access site for patients being at high or even low risk for bleeding complications.