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Severe tricuspid regurgitation (TR) is a complex condition of the right ventricle and tricuspid valve apparatus and frequently associated with symptomatic heart failure and significant morbidity and mortality [(1)][1]. In contrast to other types of valve disease, TR is seldom an isolated valve

Introduction: The feasibility of fractional flow reserve (FFR)-guided angioplasty using paclitaxel-coated balloons without stent implantation (DCB-only PCI) has been investigated in the OCTOPUS-2 trial (NCT02120859). According to the study protocol, dissections classified as NHLBI types A and B were not stented, if FFR > 0.8 and residual stenosis Hypothesis: We evaluated the extent of residual dissections using the optical coherence tomography (OCT) recordings obtained at 6-month follow-up (f/u). Methods: A number of 41 pt with 45 lesions were successfully treated by FFR-guided DCB-only PCI and underwent 6-month angiographic and OCT f/u. OCT analysis included manual tracing of dissections and plaques, which were entered into a dedicated software program. The algorithm enabled beyond the spread-out vessel reconstruction ("carpet view" of inner vessel surface: Fig. 1) also the computation of volume, luminal surface area and length of dissections and plaques. Results: As shown in Table 1, no correlation was found between angiography and OCT at f/u regarding the presence or the extension of dissections. Angiographic dissection type, vessel diameter, lesion length, plaque burden or balloon to artery ratio were not predictive for the presence of dissection at OCT f/u. Conclusions: Clinically silent residual dissections after balloon angioplasty are largely misdiagnosed by angiography. Intracoronary imaging and FFR proved useful to guide the procedure and avoid unnecessary stenting. OCT using this novel algorithm for spread-out vessel reconstruction enables a comprehensive quantitative analysis of coronary artery dissections and plaque burden.

Objectives We aimed to assess the mechanisms of coronary steal by direct hemodynamic measurements of the collateral circulation in chronic total coronary occlusions (CTO). Background Coronary steal may cause ischemia despite well-developed collaterals in coronary artery disease. Methods Fifty-six patients were studied during recanalization of a CTO. Before recanalization, the fractional flow reserve in the donor artery (FFRD) at the takeoff of the collaterals and the coronary flow reserve were recorded. After crossing the occlusion, the distal coronary flow velocity was measured by a Doppler wire (APVOccl), and distal pressure by a pressure wire. Changes of these parameters were assessed during intravenous adenosine (140 μg/kg/min). Resistance indexes for the donor artery (RD), collaterals (RC), and microcirculation (RP) were calculated. Results Adenosine caused a decrease of APVOccl(i.e., coronary steal, in 26 patients [group S], an increase in 19 patients [group R], and no change in 11 patients). The FFRDwas lower in group S. RDand RCincreased in group S, while RDdid not change significantly and RCdecreased in group R. Patients with steal had more severe regional dysfunction. Patients with steal but without an FFRD Conclusions We could demonstrate that coronary steal in man is mainly due to a hemodynamically significant donor artery lesion, but can also occur due to an impaired vasodilatory reserve of the microcirculation in the absence of a donor artery lesion. Coronary steal may have an adverse influence on the preservation of myocardial function by collaterals.

Objectives The goal of this study was to assess the influence of collateral function, coronary hemodynamics, and the angiographic result on the risk of target vessel failure (TVF) after recanalization of a chronic total coronary occlusion (CTO). Background Collaterals may have an adverse effect on TVF. Methods In 111 consecutive patients, a CTO (duration >2 weeks) was successfully recanalized with stent implantation. Collateral function was assessed by intracoronary Doppler flow velocity and pressure recordings distal to the occlusion. Baseline collateral function was determined before the first balloon inflation, and recruitable collateral function after stenting during a balloon reocclusion. Finally, the coronary flow velocity reserve (CFVR) and the fractional flow reserve (FFR) were measured. Results Angiographic follow-up after 5 ± 1.4 months in 106 patients showed a reocclusion in 17% and a restenosis in 36%. The major determinants of TVF were the stent length (p Conclusions This study showed that there is no relation between a well-developed collateral supply and the risk of TVF in recanalized CTOs. This was rather determined by the stented segment length. There was also no adverse effect of the frequently observed impaired CFVR on TVF, whereas a low FFR was associated with a higher risk of reocclusion.

We aimed to implement (1) a standardized, computational algorithm to analyze all coronary plaques in an OCT pullback, and to introduce (2) a novel parameter - luminal plaque surface area - as a better description of plaque burden. Plaque assessment consisted of: (a) plaque count of each subtype

Background. In the catheter laboratory there is a need for functional tests validating the hemodynamic significance of coronary artery stenosis.Objectives. It was the objective of our study to compare the long-term cardiac event rate and the clinical symptoms in patients with reduced coronary flow velocity reserve (CFVR) and standard PTCA with patients with normal CFVR and deferred angioplasty.Methods. Our study included 70 patients with intermediate coronary artery stenoses (13 f, 57 m; diameter stenosis >50%

Based on data from the German Aortic Valve Registry (GARY) a novel scoring system to predict 30-days or in hospital mortality for either transvascular (tv) or transapical (ta) -TAVR was developed. 6249 pt undergoing tv-TAVR in 2011 and 2012 were included in this ongoing non-randomized national

Objectives. The aim of this study was to determine the impact of nasal nocturnal oxygen therapy on respiration, sleep, exercise capacity, cognitive function and daytime symptoms in patients with congestive heart failure and Cheyne-Stokes respiration.Background. Cheyne-Stokes respiration is common in patients with congestive heart failure and is associated with significant nocturnal oxygen desaturation and sleep disruption with arousals. Oxygen desaturations and arousals cause an increase in pulmonary artery pressure and sympathoneural activity and therefore may reduce exercise capacity. Oxygen is an effective treatment of Cheyne-Stokes respiration and should improve exercise capacity in these patients.Methods. The study was designed as a randomized, crossover, double-blind, placebo-controlled trial: 22 patients were assigned to 1 week each of nocturnal oxygen and room air. After each week, polysomnography, maximal bicycle exercise with expiratory gas analysis and trail-making test were performed, and a health assessment chart was completed.Results. Noturnal oxygen significantly reduced the duration of Cheyne-Stokes respiration (162 ± 142 vs. 88 ± 105 min [mean ± SD]; p < 0.005). Sleep improved as evidenced by less stage 1 sleep and fewer arousals (20 ± 13 vs. 15 ± 9/h total sleep time; p < 0.05) as well as more stage 2 and slow-wave sleep; nocturnal oxygen saturation also improved. Peak oxygen consumption during exercise testing increased after oxygen treatment (835 ± 395 vs. 960 ± 389 ml/min; p < 0.05). Cognitive function evaluated by the trail-making test improved, but daytime symptoms in the health assessment chart did not improve significantly.Conclusions. Successful treatment of Cheyne-Stokes respiration with nocturnal nasal oxygen improves not only sleep, but also exercise tolerance and cognitive function in patients with congestive heart failure.

Objectives.Endomyocardial biopsy samples from patients with idiopathic dilated cardiomyopathy were screened for the presence of enterovirus genome. Patients with enterovirus-positive samples were further studied with regard to disease course, histologic variables and response to interferon-alpha treatment.Background.Studies of patients with idiopathic dilated cardiomyopathy have reported widely divergent clinical outcomes, suggesting that there is no unique underlying pathogenetic mechanism.Methods.Five left ventricular endomyocardial biopsy samples were screened for the presence of the enterovirus genome by an established in situ hybridization technique in combination with a histologic, histomorphometric and immunohistologic workup. The course of the disease was then prospectively followed for up to 50 months. Virus-positive patients whose condition deteriorated were treated with interferon-alpha.Results.Of 77 patients, 20 (26%) had enterovirus-positive and 57 (74%) enterovirus-negative biopsy samples. During a mean follow-up period of 25.8 ± 13.7 months, 1 patient in the enteroviruspositive group and 11 in the enterovirus-negative group died. Four patients in the enterovirus-negative group underwent heart transplantation (p < 0.05). The surviving 19 enterovirus-positive patients had a decrease in mean left ventricular end-diastolic diameter from 66 to 61 mm (p < 0.05) and a mean increase in left ventricular ejection fraction from 0.35 to 0.43 (p < 0.05). In contrast, enterovirus-negative patients had no significant change in end-diastolic diameter or left ventricular ejection fraction. Four patients in the enterovirus-positive group whose condition deteriorated were treated with a 6-month course of subcutaneous interferon-alpha (3 × 106U every second day). This treatment induced hemodynamic improvement in all four patients and eliminated the persistent enteroviral infection in two.Conclusions.Enterovirus-positive patients have a better heart transplantation-free survival rate and hemodynamic course, with fewer histologic changes, than do enterovirus-negative patients. In addition, enterovirus-positive patients respond favorably to interferon-alpha treatment. These observations indicate that myocardial enteroviral infection with associated left ventricular dysfunction is a distinct disease entity with a benign course.

Pulmonary Hypertension (PH) is considered a significant risk factor in patients with aortic valve disease for and the prognostic implicationions of PH are unclear in high-risk patients undergoing Transcatheter Aortic Valve Implantation (TAVI). Therefore, we sought to assessed the impact of

Heterotopic valve implantation into the caval veins has been suggested to treat venous congestion in severe TR. We report our experience with this approach from basic preclinical studies to the first human treatment. Proof-of-concept studies were performed in a sheep model. Following the induction

We congratulate Laule et al. [(1)][1] for the first reported use of the 29-mm Edwards Sapien XT balloon-expandable valve (Edwards Lifesciences, Irvine, California) for transcatheter venous implantation to treat tricuspid regurgitation (TR). However, when we first investigated and clinically

Previously, we demonstrated superior suppression of neointimal proliferation of ciglitazone- eluting stents (CES) in comparison to sirolimus- and everolimus-eluting stents and bare metal stents (BMS) in rabbits. We aimed to investigate endothelial coverage of the novel CES. Non-polymeric CES were

We aimed to assess the mechanisms of coronary steal by direct hemodynamic measurements of the collateral circulation in chronic total coronary occlusions (CTO).Coronary steal may cause ischemia despite well-developed collaterals in coronary artery disease.Fifty-six patients were studied during recanalization of a CTO. Before recanalization, the fractional flow reserve in the donor artery (FFR(D)) at the takeoff of the collaterals and the coronary flow reserve were recorded. After crossing the occlusion, the distal coronary flow velocity was measured by a Doppler wire (APV(Occl)), and distal pressure by a pressure wire. Changes of these parameters were assessed during intravenous adenosine (140 microg/kg/min). Resistance indexes for the donor artery (R(D)), collaterals (R(C)), and microcirculation (R(P)) were calculated.Adenosine caused a decrease of APV(Occl) (i.e., coronary steal, in 26 patients [group S], an increase in 19 patients [group R], and no change in 11 patients). The FFR(D) was lower in group S. R(D) and R(C) increased in group S, while R(D) did not change significantly and R(C) decreased in group R. Patients with steal had more severe regional dysfunction. Patients with steal but without an FFR(D)0.8 tended to have an impaired microvascular function.We could demonstrate that coronary steal in man is mainly due to a hemodynamically significant donor artery lesion, but can also occur due to an impaired vasodilatory reserve of the microcirculation in the absence of a donor artery lesion. Coronary steal may have an adverse influence on the preservation of myocardial function by collaterals.

The goal of this study was to assess the influence of collateral function, coronary hemodynamics, and the angiographic result on the risk of target vessel failure (TVF) after recanalization of a chronic total coronary occlusion (CTO).Collaterals may have an adverse effect on TVF.In 111 consecutive patients, a CTO (duration2 weeks) was successfully recanalized with stent implantation. Collateral function was assessed by intracoronary Doppler flow velocity and pressure recordings distal to the occlusion. Baseline collateral function was determined before the first balloon inflation, and recruitable collateral function after stenting during a balloon reocclusion. Finally, the coronary flow velocity reserve (CFVR) and the fractional flow reserve (FFR) were measured.Angiographic follow-up after 5 +/- 4 months in 106 patients showed a reocclusion in 17% and a restenosis in 36%. The major determinants of TVF were the stent length (p0.01) and number of implanted stents (p0.01). No difference was observed in baseline or recruitable collateral function between patients with and without TVF; 52% of patients had a CFVRor= 2.0, and only 18% a CFVRor=2.5 after percutaneous transluminal coronary angioplasty, but neither cutoff-value predicted TVF. A low FFR discriminated patients with reocclusion (0.81 +/- 07 vs. 0.86 +/- 08, p0.05) but not with restenosis (0.87 +/- 0.06).This study showed that there is no relation between a well-developed collateral supply and the risk of TVF in recanalized CTOs. This was rather determined by the stented segment length. There was also no adverse effect of the frequently observed impaired CFVR on TVF, whereas a low FFR was associated with a higher risk of reocclusion.

Transcatheter aortic valve implantation (TAVI) has emerged as an accepted treatment alternative for high risk patients with severe aortic stenosis. This study was designed to evaluate the safety and efficacy of transapical aortic valve implantation in high risk patients using the second generation

Safety concerns regarding use of drug eluting coronary stents are related to late stent thrombosis, which is facilitated by incomplete endothelial stent coverage. Optical coherence tomography (OCT) is the new gold standard for intravascular imaging, enabling precise assessment of neointimal

OBJECTIVES The aim of this research was to assess the efficacy of paclitaxel-eluting stents in chronic total coronary occlusions (CTO). BACKGROUND Percutaneous coronary interventions for CTOs are characterized by a high target vessel failure rate. METHODS In 48 consecutive patients, paclitaxel-eluting stents (Taxus, Boston Scientific Corp., Natick, Massachusetts) were implanted after successful recanalization of a CTO (duration >2 weeks). Patients underwent an angiography after 6 months and were followed clinically for 12 months. They were compared with 48 lesion- and risk-matched patients with CTOs treated with bare metal stents (BMS). Primary clinical end point was the one-year incidence of major adverse cardiac events (MACE) (death, myocardial infarction, repeat revascularization); secondary end points were the rate of restenosis and re-occlusion. RESULTS In-hospital MACE was 4.2% with Taxus, and 2.1% with BMS (p = NS). The one-year MACE rate was 12.5% in the Taxus group, and 47.9% in the BMS group (p < 0.001), which was due to a reduced need for repeat revascularization. The angiographic restenosis rate was 8.3% with Taxus versus 51.1% with BMS (p < 0.001). There was only one late re-occlusion with Taxus (2.1%) as compared with 23.4% with BMS (p < 0.005). The late loss was reduced in the Taxus group by 84% as compared with BMS. All nonocclusive restenoses in the Taxus group were focal and successfully treated by implanting an additional Taxus stent. CONCLUSIONS The treatment of CTOs with a paclitaxel-eluting stent drastically reduces MACE and restenosis, and almost eliminates re-occlusion, which is typically frequent with BMS in CTOs. Chronic total coronary occlusion should be a preferred indication for drug-eluting stents.

There is increasing evidence that chronic enhanced exogenous or endogenous catecholamine stimulation in patients with dilated cardiomyopathy may worsen hemodynamic status and prognosis. The cause of this deterioration may lie in myocellular calcium accumulation and microcirculatory disorders. In a prospective study, the calcium channel antagonist diltiazem was given to 22 patients with dilated cardiomyopathy (60 to 90 mg three times daily) in addition to conventional therapy of digitalis, diuretics and vasodilators. Twenty-five patients received the conventional therapy and served as historical controls. Eight additional patients who were not originally included in this control group received adjunctive diltiazem treatment after initially receiving conventional therapy alone. The three patient groups were similar in all hemodynamic and anamnestic features. Only patients with reduced myofibrillar volume fraction on myocardial biopsy were included in the trial, because they could be expected to show hemodynamic deterioration. The mean survival time was 29 months in the control group, whereas no patient in the diltiazem group died over a mean follow-up period of 15.4 months (p less than 0.001). Mean left ventricular ejection fraction increased from 0.34 to 0.44 (p less than 0.001) and New York Heart Association functional class improved significantly in the diltiazem group and during the diltiazem period in the crossover patients, but deteriorated in the control group. The results suggest that adjunctive diltiazem treatment in dilated cardiomyopathy has beneficial effects on mortality, hemodynamics and symptoms.

To the Editor: Tricuspid regurgitation (TR) is common in patients with late-stage myocardial and valvular heart disease. Severe TR leads to a decrease in cardiac output (CO), and significant symptoms of right heart failure develop, such as peripheral edema and congestive hepatosplenomegaly.

Optical coherence tomography (OCT) allows precise evaluation of coronary structures. There is limited knowledge whether plaque burden plays a role in coronary healing response, or is susceptible to antiproliferative drugs or stents after PCI. We aimed to implement a 3-dimensional OCT algorithm to

Despite the recent advances in interventional treatment of heart valve disease, no transcatheter approach is established for severe tricuspid regurgitation (TR). Single valve implantation into the inferior vena cava (IVC) has been suggested, which however only partially resolves the hemodynamic

Based on data from the German Aortic Valve Registry (GARY) a novel scoring system to predict 1year-mortality in patients undergoing transcatheter aortic valve replacement was developed. 3875 pt undergoing TAVR were included national multicenter registry. One year mortality after TAVR was chosen as

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 22-year-old patient presented with hemoptysis and dyspnea on exertion. When the patient was a child, an atrial septal defect and Ebstein's anomaly had been diagnosed. The parents and the patient refused