Iatrogenic atrial septal defects after transseptal puncture for percutaneous left atrial appendage occlusion and their hemodynamic effects.

Background: Percutaneous left atrial appendage occlusion (LAAO) requires puncture of the interatrial septum. The immediate hemodynamic effects of iatrogenic atrial septal defects (iASD) after LAAO have not been examined so far. We aimed at evaluating these effects through invasive measurements of pressure and oxygen saturation. Moreover, we assessed the incidence of persistent iASD at three months. METHODS: Forty-eight patients scheduled for percutaneous LAAO were prospectively included in the study. Pressure and oxygen saturation were measured (1) in the right atrium (RA) before transseptal puncture, (2) in the left atrium (LA) through the transseptal sheath after transseptal puncture, (3) in the LA after removal of introducer sheath, and (4) in the RA after removal of introducer sheath. Transesophageal echocardiography was performed at three months to detect iASD. RESULTS: Pressure in the RA increased significantly after removing the introducer sheath (P = 0.034), whereas no difference was found in oxygen saturation in the RA (P = 0.623). Pressure measurement in the LA showed no significant difference after removing the introducer sheath (P = 0.718). Oxygen saturation in the LA also showed no significant difference (P = 0.129). Follow-up transesophageal echocardiogram at 3 months revealed a persistent iASD in 4 patients (8.5 %). CONCLUSIONS: Our study suggests that iASD after percutaneous LAAO does not result in significant shunts directly after the procedure, although a significant increase of mean right atrial pressure can be observed. Persistent iASDs after percutaneous LAAO seem to be relatively rare at three months.

Percutaneous left atrial appendage occlusion in a frail, high-risk, octogenarian patient population, after having undergone transcatheter aortic valve implantation.

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) represents an alternative stroke prevention method in patients with atrial fibrillation and an increased bleeding risk, chronic kidney disease or contraindications to oral anticoagulants. Aim of our study was to evaluate the feasibility and safety of percutaneous LAAO in high-risk, frail patients having undergone transcatheter aortic valve implantation (TAVI). METHODS: Thirty-one patients having undergone TAVI and scheduled for LAAO were prospectively included in our study. RESULTS: Implantation was successful in 29 of 31 cases (93.5%).There were no patients that developed a major acute cardiovascular event, stroke, or device dislocation/embolization. There was a single case of major bleeding (3.2%) and 3 cases of acute kidney injury (9.7%). At 3 months, no patients experienced a stroke, one patient had a device-related thrombus (3.4%), one patient showed a significant peri-device leak, and one patient had a persistent iatrogenic atrial septal defect. CONCLUSIONS: Our study shows that percutaneous LAAO may represent a feasible alternative strategy for stroke prevention, that can be safely performed in high-risk, multimorbid patients with high bleeding risk or contraindications to oral anticoagulation.

Comparison of effectiveness and survival after the MitraClip or Carillon procedure for severe functional mitral regurgitation: a single-center retrospective analysis.

INTRODUCTION: Current studies suggest improved survival in patients with severe functional mitral regurgitation (FMR) treated successfully with the MitraClip (MC) compared to medical treatment alone, in addition to a significant reduction of FMR severity. Recently, the Carillon system (CS) has also been shown to significantly reduce FMR. However, whether this beneficial effect of CS also translates into a survival benefit comparable to the MC system has not been investigated so far. The aim of the study was to compare the course of FMR grade and mortality after MC or CS in a retrospective, non-randomized, single-center analysis. MATERIAL AND METHODS: A hundred and fifty-four patients with symptomatic FMR 2+ were included in this study (MC: n = 117, CS: n = 37). Baseline characteristics did not differ significantly between groups. RESULTS AND CONCLUSIONS: Initially, the degree of FMR was reduced in the MC group from 2.9 ±0.3 to 1.7 ±0.7 and from 2.7 ±0.5 to 2.1 ±0.7 in the CS group, p within and between groups < 0.01. Within 6 months, FMR remained reduced in the MC group (1.83 ±0.6) and CS group (2.1 ±0.7). One-year survival was 34.8% in the MC group and 54.8% in the CS group (p = 0.663). Median long-term survival was 1.66 years in the MC group and 3.92 years in the CS group, log rank p = 0.001.

Comparison of transthoracic and transesophageal echocardiography for transcatheter aortic valve replacement sizing in high-risk patients.

BACKGROUND: Untreated symptomatic high-grade aortic stenosis remains a lethal disease requiring individually adapted valve replacement. High-risk surgical patients benefit from transcatheter aortic valve replacement (TAVR), but there is no uniform standard for patient selection and valve sizing and it is still unclear whether transthoracic (TTE) or transesophageal (TEE) echocardiography is superior in preprocedural aortic annulus sizing. As preprocedural sizing of the native aortic annulus diameter is crucial to outcome and survival, we report the results of a direct comparison between preprocedural sizing with TTE and TEE including subsequent outcomes in a high-risk TAVR population. METHODS: A total of 149 TAVR patients were enrolled for TTE and TEE comparison, and an additional 15 patients without structural heart disease were investigated as control group to determine the influence of aortic valve calcification on TTE and TEE aortic annulus diameter measurements. RESULTS: Overall standardized TTE and TEE measurements for aortic annulus sizing showed excellent correlation at good image quality (p < 0.01, r = 0.934). Calcification of the aortic annulus diameter was not found to exert a noteworthy negative influence on measurements for both standardized TTE and TEE and complication rates did not differ for mortality, periprocedural stroke and paraprosthetic regurgitation. CONCLUSIONS: Transthoracic echocardiography and TEE are both equally suitable methods of preprocedural aortic annulus size evaluation in preparation of TAVR procedures.

The STS score is the strongest predictor of long-term survival following transcatheter aortic valve implantation, whereas access route (transapical versus transfemoral) has no predictive value beyond the periprocedural phase.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) was developed as a promising new therapy for inoperable and surgical high-risk patients as an alternative to traditional aortic valve replacement. After a successful procedure, prognosis may mainly be determined by comorbidities. However, no appropriate risk score to predict long-term outcome following TAVI is currently available. The aim of this study was to identify predictors of adverse short- and long-term outcomes. METHODS: This is a two-centre registry study including a total of 426 TAVI procedures (274 transfemoral [TF] and 152 transapical [TA]) performed at the University Hospital and CardioVascular Center of Frankfurt (Germany) between 2005 and 2011. RESULTS: Observed 30-day mortality was 4.8% among TF and 12.6% among TA patients (hazard ratio [HR] TF vs TA was 0.38; 95% confidence interval [CI] 0.19-0.77). Patients with a higher Society of Thoracic Surgeons (STS) score experienced a 6% elevation in the 30-day mortality per point (HR 1.06; 95% CI 1.03-1.10), whereas the predictive value of the logistic EuroSCORE (HR 1.03; 95% CI 1.01-1.05) and EuroSCORE 2 (HR 1.04; 95% CI 1.01-1.07) was slightly lower. Most interestingly, older age (>80 years) and the access type were predictors of 30-day mortality. However, the only independent predictor of long-term mortality in a 30-day landmark analysis was the STS score (HR 1.05; 95% CI 1.02-1.09). CONCLUSIONS: The STS score outperforms the logistic EuroSCORE in predicting adverse outcomes following TAVI. The transapical approach is associated with higher perioperative mortality, but does not exert any influence on long-term prognosis beyond the periprocedural phase.

Safety and feasibility of transcatheter aortic valve implantation in patients with severe persistent thrombocytopenia.

Untreated symptomatic high-grade aortic stenosis remains a lethal disease. Therefore, a comprehensive evaluation is necessary to obtain the best individual treatment for each patient. Recently, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for high-risk and inoperable patients. Persistent thrombocytopenia is an established risk for conventional open heart surgery, but is not covered by traditional surgical risk scores. The aim of the study was the investigation of safety and feasibility of TAVI in patients with severe thrombocytopenia. Because of the complicated outcome of patients with persistent thrombocytopenia undergoing heart surgery, we considered all patients with high-grade aortic stenosis and a thrombocyte count of less than 100 per nl as surgical high-risk patients. Out of these high-risk surgical patients, six patients with symptomatic high-grade aortic stenosis and severe thrombocytopenia were deemed to be TAVI candidates and underwent TAVI procedures in 2010 and 2011 (transfemoral: n = 4; transapical: n = 2) at the University Hospital of Frankfurt. The outcome of these patients was analyzed prospectively in order to document safety and feasibility of TAVI in such patients. All TAVI procedures were performed successfully with excellent functional results. There was no occurrence of major or minor bleeding complications, acute renal failure or nosocomial infection. One patient died of an ischemic stroke 12 days after the procedure. The five remaining patients were alive at the 12-month follow-up without relevant cardiovascular events and excellent valve performance. TAVI is an effective and well tolerated method to treat patients with chronic persistent thrombocytopenia and symptomatic high-grade aortic stenosis, and therefore a reasonable alternative to conventional heart surgery in such patients. The indication for TAVI in patients with thrombocytopenia and symptomatic high-grade aortic stenosis might be generated independently from conventional scoring systems.

Transcatheter aortic valve implantation improves outcome compared to open-heart surgery in kidney transplant recipients requiring aortic valve replacement.

BACKGROUND: Cardiovascular disease is the most frequent cause of mortality for kidney transplant recipients. Open heart surgery has particularly high mortality and morbidity. As an alternative to traditional aortic valve replacement (AVR) for patients with high-grade aortic stenosis, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for patients considered at high surgical risk. METHODS: We considered all kidney transplant recipients as high-risk patients, which are candidates for TAVI. In 2010 and 2011, eight kidney transplant recipients with severe aortic stenosis underwent TAVI (6 transfemoral; 2 transapical; group I). The outcome of these patients was compared retrospectively to 18 kidney transplant recipients with aortic stenosis, who underwent conventional AVR (group II). RESULTS: Both groups had similar baseline characteristics, including estimated perioperative risk (EuroSCORE group I vs. group II: 9.5±5.9 vs. 10.4±10.5; p=0.829). All TAVI procedures were performed successfully with excellent functional results. In the TAVI group (group I), all patients were alive at the 12-month follow-up with one cardiovascular event (stroke). In contrast, the surgical group experienced a 30-day-mortality of 11.1% (n=2) and a 1-year-mortality of 16.7% (n=3). CONCLUSIONS: Based on our center's experience, TAVI appears to be an effective and safe alternative to conventional surgery for AVR in patients with prior renal transplantation. Renal transplantation is not currently identified as a risk factor in our traditional scoring system, and may need to be considered independently when weighing alternatives for AVR.

Extensive dissecting aneurysm of the ascending aorta.

We present the case of a 69-year-old female surviving an extensive dissecting thoracic aortic aneurysm. Due to the initial presentation with angina and epigastric pain the first working diagnosis was acute coronary syndrome. However, on transthoracic and transesophageal echocardiography (TEE), the dissecting aneurysm (type Stanford A) could be detected. Our article stresses the importance of imaging for the rapid and accurate diagnosis of thoracic aortic aneurysms with dissection. In our case, TEE detected the intimal flap separating true and false lumen, and the consecutive hemodynamically relevant aortic valve regurgitation, in addition to the aneurysm extent. The patient underwent surgical repair with aortic arch replacement and recovered without sequelae. .