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Aims Transcatheter treatment of heart valve disease is well established today. However, for the treatment of tricuspid regurgitation (TR), no effective catheter-based approach is available. Herein, we report the first human case description of transcatheter treatment of severe TR in a 79-year-old patient with venous congestion and associated non-cardiac diseases. In this patient, surgical treatment had been declined and pharmacological therapy had been ineffective. After ex vivo and animal studies, the treatment of TR was performed by percutaneous caval valve implantation. Methods and results In a transcatheter approach through the right femoral vein, a custom-made self-expanding heart valve was implanted into the inferior vena cava (IVC). The device was anchored in the IVC at the cavoatrial junction with the level of the valve aligned immediately above the hepatic inflow and protruding into the right atrium. After deployment, excellent valve function was observed resulting in a marked reduction in caval pressure and an abolition of the ventricular wave in the IVC. Sequential echocardiographic exams over a follow-up period of 8 weeks confirmed continuous device function without paravalvular leakage or remaining venous regurgitation. The patient experienced improved physical capacity and was able to resume off-bed activities. There was no recurrence of right heart failure during follow-up and a partial reduction of ascites. The patient was discharged from hospital into a rehabilitation programme. Conclusion Transcatheter treatment of severe TR by caval valve implantation is feasible resulting in an immediate abolition of IVC regurgitation and mid-term clinical improvement. Thus, in selected non-surgical patients, caval valve implantation may become a therapeutic option to treat venous regurgitation and improve associated non-cardiac diseases. Further confirmatory experience with longer follow-up is required to evaluate the long-term clinical benefit of the procedure as well as potential deleterious effects.

Aims Severe tricuspid regurgitation (TR) reduces cardiac output (CO) and increases central venous pressure leading to secondary organ dysfunction. To date, the open surgical approach is the only option to treat TR. Herein, we report our experience of treatment by percutaneous implantation of valved stents in the inferior vena cava (IVC) and superior vena cava (SVC) to substitute tricuspid valve function in a model of acute insufficiency. Methods and results Acute TR grades III–IV was created in 13 sheep (54–75 kg) via papillary muscle and chordae avulsion using a 0.07 inch wire blade. Successful creation of TR was confirmed using angiography and by a prominent ventricular wave in central venous pressure recording. Two self-expanding nitinol stents containing a porcine pulmonary valve were then implanted in the IVC and SVC in a transcatheter approach. Implantation was performed through the right jugular vein by means of a 21 F catheter and guided by fluoroscopy. Haemodynamics were continuously monitored and valve function was verified by angiography and epicardial echocardiography. After successful implantation and proof of concept in the acute study (acute group, n = 9), chronic studies were ( n = 4, 4 weeks follow-up) performed. Tricuspid regurgitation grades III–IV was successfully created in all animals and resulted in a significant reduction of CO. A ventricular wave in the IVC of 16.2 ± 2.33 mmHg (acute group) and 14.9 ± 1.71 mmHg (chronic group) confirmed the presence of severe TR. After deployment of the IVC and the SVC valve, the ventricular wave in the IVC significantly decreased to 13.9 ± 2.97 mmHg (acute group) and 12.7 ± 1.15 (chronic group), whereas CO significantly increased to 4.20 ± 0.84 L/min (acute group) and 5.4 ± 0.67 L/min (chronic group). At autopsy, correct device position was verified in all successfully implanted animals, no macroscopic damage resulting from the implantation procedure was observed. Conclusion In high-grade tricuspid insufficiency, percutaneous implantation of valved stents in the central venous position reduces venous regurgitation and improves haemodynamics in the animal experiment. Implantation of one or two valves in central venous position is technically feasible. Functional replacement of the insufficient tricuspid valve leads to an increase in CO. This technique expands the potential therapeutic options for patients with relevant tricuspid valve regurgitation having a high risk for open heart surgery.

An 85-year-old patient presented with global heart failure from mitral and tricuspid valve disease. In 1990, he had undergone aortic valve replacement with a tilting-disc mechanical prosthetic valve (Bjork-Shiley) which was still functioning flawlessly. At the time of admission, echocardiography and invasive diagnostics confirmed moderate-to-severe mitral stenosis and severe tricuspid regurgitation causing …

The transcatheter valve technology pipeline has started as simple balloon valvuloplasty for the treatment of stenotic heart valves and evolved since the year 2000 to either repair or replace heart valves percutaneously with multiple devices. In this review, the present technology and its application are illuminated and a glimpse into the near future is dared from a physician's perspective.

Aims Chronic total coronary occlusions (CTOs) with angiographically well-developed collaterals may be considered to provide sufficient blood supply to the occluded segment, and the indication for revascularization may be questioned. Therefore, the collateral function and functional reserve in patients with a CTO without a prior Q-wave myocardial infarction (MI) were assessed. Methods and results Invasive assessment of collateral function was done during successful percutaneous coronary intervention in 107 patients with a CTO and no prior Q-wave MI. Intracoronary Doppler flow velocity and pressure recordings were obtained distal to the occlusion before the first balloon inflation and collateral function indexes calculated. In 62 patients, additional pharmacological stress testing was done by intravenous adenosine (140 microg/kg/min) to assess the collateral flow reserve. Patients with normal and impaired regional dysfunction were compared. Collateral function was similar in patients with and without regional left ventricular (LV) dysfunction. In both groups, 78% collaterals provided a collateral pressure index at baseline > 0.3, sufficient to prevent ischaemia during a balloon occlusion, with a minimum of 0.2 in those with preserved LV function. A Doppler-derived function index showed a wider variation due to the high prevalence of microvascular dysfunction in CTOs. Only 7% of patients had an increase in collateral flow reserve > 2.0 during pharmacological stress, whereas coronary steal occurred in one-third independent of regional LV function. Conclusion A limited increase in collateral flow and the high prevalence of coronary steal during stress underscore the functional limitation of collaterals in CTOs without prior Q-wave MI. Even presumably 'well-collateralized' CTOs may benefit from a revascularization.

Chronic heart failure (CHF) is a multi-organ disease with increasing evidence for the involvement of the gastrointestinal (GI) system in this syndrome. In recent research, the gut has received very little attention from cardiologists as its role in the pathogenesis of cardiovascular disease is poorly understood. Intestinal ischaemia may play an important role in bacterial translocation by increasing bowel permeability. Decreased cardiac function can reduce bowel perfusion and so clearly impairs the function of the intestinal barrier. There is an increasing evidence to suggest that a 'leaky' bowel wall may lead to translocation of bacteria and/or endotoxin, which may be an important stimulus for inflammatory cytokine activation in CHF. Impaired functioning of the GI system may also contribute to malnutrition and cachexia in CHF. It is hoped that by improving our understanding of the role of the gut in cardiac disease will lead to the development of novel therapeutic strategies in the future.

Background The mortality of coronary artery disease is increased in diabetic patients. An impaired collateral function is considered a possible explanation. This study should assess the influence of diabetes on collaterals by direct invasive assessment of collateral function. Methods In 90 consecutive patients with a chronic coronary occlusion (TCO) of >2 weeks duration a recanalization was done. Thirty patients with diabetes (33%) were compared with 60 (67%) without diabetes. Blood flow velocity and pressure were measured distal to the occlusion by intracoronary Doppler and pressure wires before PTCA, and again after PTCA during a final balloon reocclusion to assess acute recruitment of collaterals. Resistance indexes for collaterals (RColl) and peripheral microcirculation (RP) were calculated. Results The RColl(diabetics: 8.1±6.8 vs nondiabetics: 8.7±6.7mmHgcm−1s−1; p=0.68) and RP(5.6±4.2 vs 6.6±3.8mmHgcm−1s−1; p=0.30) were similar in diabetic and nondiabetic patients before recanalization. During balloon reocclusion both RColland RPincreased. This increase was significantly more pronounced in diabetic than in nondiabetic patients in TCOs

In a 79-year-old female patient with symptomatic tricuspid regurgitation (TR) ‘first-in-man’ transcatheter valve implantation into the inferior vena cava (IVC) was performed as compassionate treatment. Details of the procedure as well as the clinical course have been reported previously. In brief, a self-expanding pericardial valve was implanted into the …

Objectives: Renal denervation (RDN) is effective in the treatment of resistant hypertension (HTN). We investigated the impact of patient's characteristics on responder-rate and efficiency of RDN. Patients and methods: 43 patients with resistant HTN despite treatment with at least 4 antihypertensive drugs and mean systolic 24-h ambulatory BP (ABP) > 140 mmHg were treated with RDN. Patients had substantial comorbidity like diabetes (51%), coronary heart disease (25%), obstructive sleep apnoea \[OSAS\] (23%) and impaired renal function (35%). FU at 3 and 6 months consisted of clinical and biochemical evaluation and ABP monitoring. Results: Multivariate analysis of baseline patient's characteristics found that only the mean systolic ABP was a predictor for responders to RDN (OR 3.8; 95% CI, 1.4-10.2; p ≤ 0.006), whereas BMI, baseline creatinine, age, sex, medication or OSAS were not predictive. Based on these findings, patients were divided into two groups: mean baseline systolic ABP ≤ 150 (group 1) or > 150 mmHg (group 2) for univariate analysis. In patients of group 1 (n=16) the ABP reduction at 3 and at 6 months was -5/-5 mmHg (n.s.) and -1/-5 mmHg (n.s.) with a responder-rate of 31% and in patients of group 2 (n=27) -27/-9 mmHg (p150 mmHg despite multi-drug therapy.

Background and aims: Overweight and the metabolic syndrome have become major problems, especially in children and adolescents. Obesity at young age increases the risk for cardiovascular diseases and diabetes mellitus later in life. An early event in the development of cardiovascular disease is endothelial dysfunction which is found in obese young individuals. Increased activity of the enzyme arginase has been described as a central mechanism for endothelial dysfunction, especially in patients with diabetes mellitus. The aim of the study was to determine plasma levels of arginase in overweigth adolescents. Methods: Sixty-six male German adolescents (age: 15.2±1.1 years old) were included. Thirty-one of them were overweight (>90th age specific weight percentile). Besides recording clinical data, anthropometrical measurements of obesity were performed. Plasma arginase I and Tumor-Necrosis-Factor alpha (TNFα) were determined. Results: Overweight adolescents had a higher systolic blood pressure, lower high-density lipoprotein and increased levels of high-sensitive CRP. Circulating arginase I was elevated in overweight adolescents (95.8±68.2 ng/ml) compared to normal weight adolescents (39.3±26.9 ng/ml, p

Objective: Mitral Regurgitation (MR) is a common finding in non-surgical patients with severe Aortic Stenosis (AS). Herein, we assessed the impact of preoperative MR on outcome in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) based upon data of the German Aortic Valve Interventions Registry. Methods and results: Between January 2009 and June 2010, a total of 1385 patients (pts) undergoing TAVI were included in this registry (mean age 81.7±6.1, 41.9% males). 468 (33.8%) pts presented with MR ≥ grade 2, in 917 (66.2%) pts none or minor MR was observed. Pts in the MR-subgroup had a significantly lower ejection fraction (49.0±14.8% vs. 54.7±14.4%; p

A 72-year-old female patient was readmitted to hospital with recurrent heart failure NYHA III after an initially uneventful course following transcatheter aortic valve implantation (TAVI). Four month earlier she had undergone TAVI for severe aortic stenosis with a 26-mm balloon-expandable aortic valve in a transfemoral approach. Initially after the procedure …