Surface and intracardiac ECG for discriminating conduction disorders after CoreValve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been developed to minimize operative morbidity and mortality in high-risk symptomatic patients unfit for open surgery. With the proximity of the aortic valve annulus to the conduction system there is, however, an unknown risk of conduction disturbances necessitating monitoring and often cardiac pacing. MATERIALS AND METHODS: We enrolled 50 consecutive patients from January 2007 to 2008 in our prospective evaluation of conduction disturbances measured by surface and intracardiac ECG recordings. Baseline parameters, procedural characteristics as well as twelve-lead surface ECG and intracardiac conduction times were revealed pre-interventionally, after TAVI and at 7-day follow-up. RESULTS: TAVI was performed successfully in all patients. During 7 days of follow-up the rate for first-degree AV block raised from 14% at baseline to 44% at day 7 (p < 0.001), while rates for type II second- and third-degree were 0 versus 8% (p < 0.001) and 0 versus 12% (p < 0.001), respectively. Similarly, the prevalence of new left bundle branch block (LBBB) rose from 2 to 54% (p < 0.001). Intracardiac measurements revealed a prolongation of both AH and HV interval from 123.7 ± 41.6 to 136.6 ± 40.5 ms (p < 0.001) and from 54.8 ± 11.7 to 71.4 ± 20.0 ms (p < 0.001), respectively. Pacemaker implantation at a mean follow-up of 4.8 ± 1.2 days was subsequently performed in 23 patients (46%) due to complete AV block (12%) and type II second-degree AV block (8%) while another 13 patients (26%) received a pacemaker for the combination of new LBBB with marked HV prolongation. The high rate of first-degree AV block was primarily driven by an increase in HV interval. CONCLUSION: Cardiac conduction disturbances were common in the early experience with CoreValve implantation necessitating close surveillance for at least 1 week.

Enhanced mobilization of the bone marrow-derived circulating progenitor cells by intracoronary freshly isolated bone marrow cells transplantation in patients with acute myocardial infarction.

Autologous bone marrow cell transplantation (BMCs-Tx) is a promising novel option for treatment of cardiovascular disease. We analysed in a randomized controlled study the influence of the intracoronary autologous freshly isolated BMCs-Tx on the mobilization of bone marrow-derived circulating progenitor cells (BM-CPCs) in patients with acute myocardial infarction (AMI). Sixty-two patients with AMI were randomized to either freshly isolated BMCs-Tx or to a control group without cell therapy. Peripheral blood (PB) concentrations of CD34/45(+) - and CD133/45(+)-circulating progenitor cells were measured by flow cytometry in 42 AMI patients with cell therapy as well as in 20 AMI patients without cell therapy as a control group on days 1, 3, 5, 7, 8 and 3, 6 as well as 12 months after AMI. Global ejection fraction (EF) and the size of infarct area were determined by left ventriculography. We observed in patients with freshly isolated BMCs-Tx at 3 and 12 months follow up a significant reduction of infarct size and increase of global EF as well as infarct wall movement velocity. The mobilization of CD34/45(+) and CD133/45(+) BM-CPCs significantly increased with a peak on day 7 as compared to baseline after AMI in both groups (CD34/45(+): P < 0.001, CD133/45(+): P < 0.001). Moreover, this significant mobilization of BM-CPCs existed 3, 6 and 12 months after cell therapy compared to day 1 after AMI. In control group, there were no significant differences of CD34/45(+) and CD133/45(+) BM-CPCs mobilization between day 1 and 3, 6 and 12 months after AMI. Intracoronary transplantation of autologous freshly isolated BMCs by use of point of care system in patients with AMI may enhance and prolong the mobilization of CD34/45(+) and CD133/45(+) BM-CPCs in PB and this might increase the regenerative potency after AMI.

TEVAR: the solution to all aortic problems?

Chronic as well as acute diseases of the thoracic aorta are attracting increasing attention, both in the light of an ageing Western and Oriental population and with the proliferation of modern diagnostic imaging modalities. While classic surgical strategies still dominate the treatment of pathology of the ascending aorta and the proximal arch region, new endovascular concepts are emerging and are likely to evolve as primary treatment strategies for descending and abdominal aortic pathology. Additionally, aortic arch pathologies are becoming the target of hybrid approaches combining surgical head-vessel debranching and interventional stent-graft implantation in an attempt to improve outcome by avoiding the high risk of open arch repair or complete replacement. Nonetheless, due to the complexity of the underlying vascular disease, each patient should be discussed in a team consisting of cardiologists, cardiac surgeons, and an imaging specialist in order to design an individualized therapeutic strategy carried out best in a center with experience in both endovascular and surgical procedures.

Tratamiento en la disección aórtica torácica con prótesis endovascular / Treatment of the thoracic aortic dissection with stents

El tratamiento de endoprótesis endovascular para la disección aórtica aparece con buenos resultados a mediano tiempo. Las posteriores indicaciones, por ejemplo, tanto la disección del arco aórtico como las disecciones aórticas agudas no complicadas se encuentran bajo estudio.

O tratamento de endoprótese endovascular para a dissecção aórtica aparece com bons resultados a médio prazo. As posteriores indicações, por exemplo, tanto a dissecção do arco aórtico quanto as dissecções aórticas agudas não complicadas se encontram sob estudo.

Endovascular stent-graft therapy for aortic dissection is emerging with good midterm results. Further indications, i.e. aortic arch dissection and uncomplicated acute aortic dissections, are under evaluation.

Second- and third-generation drug-eluting coronary stents: progress and safety.

Drug-eluting stents (DES) have revolutionized the treatment of coronary artery disease by reducing the rate of in-stent restenosis from 20-40% with bare-metal stent (BMS) to 6-8% with DES. However, with widespread use of DES, safety concerns have risen due to the observation of late stent thrombosis. With this in mind and better understanding of mechanism and pathophysiology of stent thrombosis, the technological platform, especially innovative anti-restenotic agents, polymeric coatings, and stent platforms, improved with newer DES. Two second-generation DES, the Endeavor zotarolimus-eluting stent (ZES) and the Xience-V everolimus-eluting stent (EES), have provided promising results in both randomized controlled trials (SPIRIT and ENDEAVOR) and registries (E-Five, COMPARE) compared with bare-metal stents (BMS) and first-generation DES. Newer third-generation stent technology, especially biodegradable polymers, polymer-free stents, and biodegradable stents on the basis of poly-L-lactide (PLLA) or magnesium, has been evaluated in preclinical and initial clinical trials. However, despite encouraging initial results, long-term data of large-scale randomized trials as well as registries comparing them to currently approved first- and second-generation DES are still lacking.

Improved functional activity of bone marrow derived circulating progenitor cells after intra coronary freshly isolated bone marrow cells transplantation in patients with ischemic heart disease.

OBJECTIVES: There is growing evidence that intracoronary autologous bone marrow cells transplantation (BMCs-Tx) in patients with chronic myocardial infarction beneficially affects postinfarction remodelling. In this randomized controlled study we analyzed the influence of intracoronary autologous freshly isolated bone marrow cells transplantation by use of point of care system on cardiac function and on the functional activity of bone marrow derived circulating progenitor cells (BM-CPCs) in patients with ischemic heart disease (IHD). METHODS: 56 patients with IHD were randomized to either received freshly isolated BMC-Tx or a control group that did not receive cell therapy. The functional activity of BM-CPCs in peripheral blood (PB) was measured by migration assay and colony forming unit assay pre- and 3, 6 as well as 12 months after procedure. Global ejection fraction (EF) and infarct size area were determined by left ventriculography. RESULTS: Intracoronary transplantation of autologous freshly isolated BMCs led to a significant reduction of infarct size and an increase of global EF as well as infarct wall movement velocity after 3 and 12 months follow-up compared to control group. The colony-forming capacity of BM-CPCs significantly increased 3, 6 and 12 months after cell therapy compared to pre BMCs-Tx and control group (CFU-E: p < 0.001, CFU-GM: p < 0.001). Likewise, we found significant increase of migratory response to stromal cell-derived factor 1 (SDF-1) and vascular endothelial growth factor (VEGF) after cell therapy compared to pre BMCs-Tx (SDF-1: p < 0.001, VEGF: p < 0.001) and to control (SDF-1: p < 0.001, VEGF: p < 0.001). There was no significant difference of migratory- and colony forming capacity between pre- and 3, 6, 12 months after coronary angiography in control group without cell therapy. CONCLUSIONS: Intracoronary transplantation of autologous freshly isolated BMCs by use of point of care system may lead to improvement of BM-CPCs functional activity in peripheral blood, which might increase the regenerative potency in patients with IHD.

[Interventional closure of persistent foramen ovale in patients after crytogenic stroke]. / Interventioneller Verschluss des persistierenden Foramen ovale nach kryptogenem Insult.

A persistent foramen ovale can be a possible cause of paradoxical cerebral embolism. Thranscatheter closure by transcatheter technique has a high success rate and is a recurrence prevention measure. This paper reviews of patent foramen ovale anatomy, pathophysiology, and clinical impact and discusses current therapeutic options.

[Coronary intervention - which indications are controversial?]. / Interventionelle Koronarintervention - welche Indikationen sind umstritten?

Actually, the further development of surgical and interventional techniques enables the treatment of complex coronary artery disease of severely ill patients. Due to this development there is a growing spectrum of possible indications for the interventional technique. Since SYNTAX trial, the individual risk stratification and discussion of possible strategies in interdisciplinar meetings is of utmost importance again. Risk stratification should contain patients history, as well as objective findings like extent of coronary artery disease, left ventricular function, pathological stress tests and patients comorbidities. Today, controversial indications up until a short time ago were possible indications for interventional techniques like demonstrated in recent trials and registries. The most discussed controversial indications were interventions at multivessel-disease with drug-eluting stents (DES), left-main stem and chronic total occlusions.

[Use of diuretics in acute decompensated heart failure]. / Einsatz von Diuretika bei der akut dekompensierten Herzinsuffizienz.

Patients with acute heart failure usually present with dyspnoe and edema secondary to elevated intracardiac filling pressure resulting from volume overload. Despite significant progress in understanding heart failure, the treatment strategy for acute heart failure did not change in the same way. Diuretics, especially loop diuretics, are the most common therapy used in this setting. Intravenous diuretics act acutely by exerting a modest vasodilatory response and chronically by reducing circulating blood volume. Despite near universal use of diuretics in patients hospitalized with acute heart failure, nearly half of these patients are discharged from hospital without weight loss. This could be due to inadequate diuresis, overdiuresis with subsequent volume replacement and diuretic resistance. Aggressive diuresis carries a significant risk of electrolyte and volume depletion with subsequent arrythmias, hypotension, and worsening renal function. Actually there were scant data available from randomized clinical trials to guide therapeutic choice with diuretics. Thus, the choice and dosing of diuretic therapy must be individualized based on general knowledge of potency and pharmacokinetic and pharmacodynamic considerations.

[Diagnosis and medical treatment of pulmonary arterial hypertension]. / Diagnostik, Therapie und Prognose der idiopathischen pulmonal-arteriellen Hypertonie.

The idiopathic pulmonal arterial hypertension is characterized by a chronic proliferative conversion of the pulmonary arterial vessels leading to an increase of pulmonary vascular resistance and thus resulting in right heart failure and increase mortality rate. With growing advances in understanding of the underlying pathophysiological mechanisms and the development of modern medical treatment strategies, there is a significant improvement of the overall survival rate and quality-of life. In this review we will give an overview about the current knowledge of etiology, diagnosis and management of idiopathic pulmonal arterial hypertension.

[Perioperative antiplatelet therapy of patients with coronary stents]. / Perioperatives Management der Thrombozytenaggregationshemmung nach koronarer Stentimplantation.

The most feared complication after coronary stent implantation is the acutely occurring stent thrombosis, which usually leads to a myocardial infarction with its relatively high mortality. Dual antiplatelet therapy with acetylsalicylic acid and clopidogrel is currently the standard therapy after coronary stent implantation to prevent a life-threatening stent thrombosis. Surgery appears to increase the risk of stent thrombosis, myocardial infarction, and death, particularly when patients undergo surgery early after stent implantation. The incidence of complications is further increased when dual-antiplatelet therapy is discontinued preoperatively. This article reviews the current data of perioperative problems in patients after percutaneous coronary intervention.

[Percutaneous aortic valve replacement in high risk patients]. / Die perkutane Implantation von Aortenklappen bei Hochrisikopatienten.

The degenerative, calcified aortic stenosis is the most common form of adult valvular heart disease. Surgical aortic valve replacement is the method of choice and can be performed at low risk in suitable candidates. However, a fair amount of patients is rejected from surgery due to old age and preexisting comorbidities increasing operative mortality. For this reason frequently operation is not accomplished. Today, with the development of percutaneous aortic valve replacement, the treatment of aortic stenosis has entered a new era providing a new durable treatment option.

[Positive influence on cardiovascular risk factor by blocking the endocannabinoid system]. / Positive Beeinflussung kardiovaskulärer Risikofaktoren durch Blockade des Endocannabinoidsystems.

Intra-abdominal fat mass, or central adiposity, and cardiovascular risk are strongly correlated. Adipose tissue is an endocrine organ that secretes hormones and cytokines influencing appetite, energy metabolism, and atherosclerosis. Rimonabant is the first selective blocker of the cannabinoid-1 receptor in development for the treatment of obesity, diabetes mellitus typ 2, and cardiometabolic risk factors. This article provides an review of efficacy of rimonabant the first selective blocker of the cannabinoid-1 receptor.

[The diagnostic dilemma of acute thoracic pain]. / Das diagnostische Dilemma des akuten Thoraxschmerzes.

Acute aortic dissection is gaining recognition in Western societies, and is being diagnosed with increasing frequency. New diagnostic imaging modalities, longer life expectancy in general, as well as the increase in the number of hypertension patients have all contributed to the growing awareness of aortic dissections. Compared with acute coronary syndrome and lung embolism, aortic dissection is among the most frequently diagnosed life-threatening conditions involving chest pain. Here we report the case of a 59 year old patient suffering from hypertension and discuss the latest diagnostic and therapeutic procedures in the setting of acute chest pain.

Interventional strategies for treatment of aortic dissection.

Endovascular treatment of chronic aneurysmatic diseases of the thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy. The emerging of endovascular strategies for acute thoracic aortic dissection is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined at present as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture have shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as all technical aspects of this fascinating new therapeutic alternative. Moreover, the currently available data from small studies and registries are commented and analysed. Based on the available information the cardiovascular community is in the early phase of integrating a new rapidly evolving interventional concept into the care of patients with type B aortic dissection that so far lacked a reasonable therapeutic option other than blood pressure lowering medication. With the use and interpretation of current information the reader will understand the potential of interventional stent-graft induced thoracic aortic repair in type B aortic dissection.

[Hematothorax after sudden chest pain]. / Hämatothorax nach plötzlichem Brustkorbschmerz.

HISTORY: A 75-year-old woman was admitted to hospital because of the sudden onset of acute chest pain and dyspnea after defecation. INVESTIGATIONS: The initial working diagnosis was pulmonary embolism because of the clinical findings, laboratory results of elevated fibrin breakdown products and abnormal lung scintigraphy. However, persistent hemorrhagic pleural effusion on contrast enhanced computed tomography and magnetic resonance imaging subsequently revealed imminent rupture of the aorta from penetrating ulceration of the aorta with surrounding intramural hematoma. TREATMENT AND COURSE: Immediate implantation of an aortic stent-graft stopped leakage from the aorta and stabilized the patient's hemodynamic state. At follow up three months later the patient was without thoracic or cardiac symptoms. CONCLUSION: After exclusion of an acute coronary syndrome computed tomography imaging should always be performed in case of acute chest pain with no established cause. Interventional stent-graft placement can be an efficacious treatment option for emergency repair of imminent rupture in the descending aorta.

[Stent-graft implantation in the thoracic aorta. Results of an interdisciplinary survey in Germany]. / Thorakale Aorten-Stentgraftimplantation. Ergebnisse einer interdisziplinären Umfrage in Deutschland.

BACKGROUND AND OBJECTIVE: Endovascular stent-graft placement is emerging as a novel therapeutic option in patients with disease of the descending thoracic aorta. Quality standards for performing stent-graft procedures as well as for pre- and postoperative patient management are lacking, so far. It was the aim of this present survey to assess the current therapeutic standard of thoracic aortic stent-graft placement in Germany. METHODS: In a nationwide survey, a total of 206 vascular surgical, radiologic, cardiologic, and cardiothoracic surgical departments were contacted. Data concerning preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized questionnaire comprising 29 items. Data analysis was performed using univariate analysis. RESULTS: 184 (89.3 %) of the 206 departments participated in the survey. Of these, 71 centers reported intending to perform or having performed thoracic aortic stent-graft placement. The survey overall represents 2267 endovascular stent-graft procedures performed in Germany between 1997/98 and 2003. On average, 7.4 stent-graft procedures/year were performed by each center, with half the centers performing fewer than 5 procedures/year. Thoracic aortic aneurysms was the main indication for endovascular stent-graft placement, followed by aortic dissection. There were significant differences between the different medical specialties which perform stent-graft procedures with respect to indications, choice of preoperative and intraoperative imaging methods, and technical equipment. There was strong agreement between the different centers concerning the necessity of a life-long follow-up after stent-graft placement, with computed tomography being the preferred imaging technique (90 % of centers). CONCLUSION: The present survey documents an increasing use of endovascular stent-graft placement in patients with disease of the descending thoracic aorta. There were differences regarding the technical execution of this procedures between specialties with respect to indication, procedure planning, and practical-technical aspects of stent-graft placement.

Percutaneous transcatheter closure of patent foramen ovale.

In presence of a patent foramen ovale (PFO) with cryptogenic cerebral embolism, traditional therapy consists of oral anticoagulation or antiplatelet therapy. Surgery was considered only in case of recurrence. Transcatheter closure of PFO is currently performed. The availability of new user friendly devices and the increasing knowledge of pathophysiology, epidemiology, and follow-up of these patients has broadened the indications and marked reduced morbidity related to interventional PFO closure. This review presents the current knowledge and our own data concerning transcatheter closure of PFO.