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This position statement is an update to the 2011 consensus statement of the Austrian Society of Cardiology (OKG) and the Austrian Society of Cardiac Surgery (OGTHG) for transfemoral transcatheter aortic valve implantation. Due to a number of recently published studies, broadening of indications and recommendations of medical societies and our own national developments, the OKG and the OGHTG wish to combine the 2017 ESC/EACTS guidelines for the management of valvular heart disease with a national position paper and to focus on certain details for the application in Austria. Thus, this position statement serves as a supplement and further interpretation of the international guidelines.

Degenerative aortic valve stenosis is an inflammatory process that resembles atherosclerosis. Neutrophils release their DNA upon activation and form neutrophil extracellular traps (NETs), which are present on degenerated aortic valves. NETs correlate with pressure gradients in severe aortic stenosis. Transcatheter aortic valve replacement (TAVR) is an established treatment option for aortic valve stenosis. Bioprosthetic valve deterioration promoted by inflammatory, fibrotic and thrombotic processes limits outcome. Deoxyribonuclease is a natural counter mechanism to degrade DNA in circulation. In the present observational study, we investigated plasma levels of double-stranded DNA, deoxyribonuclease activity and outcome after TAVR. 345 consecutive patients undergoing TAVR and 100 healthy reference controls were studied. Double-stranded DNA was measured by fluorescence assays in plasma obtained at baseline and after TAVR. Deoxyribonuclease activity was measured at baseline using single radial enzyme diffusion assays. Follow-up was performed at 12 months, and mean aortic pressure gradient and survival were evaluated. Receiver operating characteristic, Kaplan-Meier curves and Cox regression models were calculated. Baseline double-stranded DNA in plasma was significantly higher compared to healthy controls, was increased at 3 and 7 days after TAVR, and declined thereafter. Baseline deoxyribonuclease activity was decreased compared to healthy controls. Interestingly, low deoxyribonuclease activity correlated with higher C-reactive protein and higher mean transaortic gradient after 12 months. Finally, deoxyribonuclease activity was a strong independent predictor of outcome 12 months after TAVR. Deoxyribonuclease activity is a potential biomarker for risk stratification after TAVR. Pathomechanisms of bioprosthetic valve deterioration involving extracellular DNA and deoxyribonuclease merit investigation.

Background Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited. Purpose To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI. Methods and results We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor. Conclusion Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

OBJECTIVES This study sought to investigate the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS).BACKGROUND Current guidelines recommend the use of TAVR only in institutions with a department for cardiac surgery on site.METHODS In this analysis of the prospective multicenter Austrian TAVI registry, 1,822 consecutive high-risk patients with severe symptomatic aortic stenosis undergoing transfemoral TAVR were evaluated. A total of 290 (15.9%) underwent TAVR at no-iOSCS centers (no-iOSCS group), whereas the remaining 1,532 patients (84.1%) were treated in iOSCS centers (iOSCS group).RESULTS Patients of the no-iOSCS group had a higher perioperative risk defined by the logistic EuroSCORE (20.9% vs. 14.2%; pCONCLUSIONS Patients undergoing transfemoral TAVR in hospitals without iOSCS had a significantly higher baseline risk profile. After propensity score matching short-and long-term mortality was similar between centers with and without iOSCS. (c) 2018 by the American College of Cardiology Foundation.

Transradial access (TRA) in percutaneous coronary intervention (PCI) is a widely used standard technique with lower complication rates compared to transfemoral access (TFA). The aim of this study was to evaluate the impact of TRA versus TFA for PCI on clinically significant vascular access complications in the setting of acute myocardial infarction (AMI). This multicenter study randomly assigned 250 patients in a 1:1 fashion (TRA vs. TFA) admitted with or without ST-segment elevation AMI undergoing immediate PCI. The primary endpoint was defined as the occurrence of hematoma, pseudo-aneurysm or local bleeding at the access site requiring any further intervention and/or prolonged hospital stay. Radiation exposure to the patient and operator was also investigated. In the study cohort (N = 250 patients, mean age 62 ± 12.7 years, 76% males) 5 patients (2%) achieved the primary endpoint without a significant difference between groups, 4 out of 125 (3.2%) in the TFA group and 1 out of 125 (0.8%) in the TRA group (p = 0.17). Access site hematoma was significantly more frequent in the TFA group compared to the TRA group (24.8% vs. 8.8%, respectively; p < 0.0007). Local bleeding was only seen in the TFA group (3.2% vs. 0%, p = 0.04). Time intervals from admission to catheter laboratory to first balloon inflation were longer in the TRA compared to the TFA group (34 ± 17 min vs 29.5 ± 13 min, respectively; p = 0.018). Radiation exposure to the patient and operator was identical. The use of TRA was accompanied by lower rates of access site complications; however, the need for subsequent treatment or prolonged hospital stays was not observed using either of the two access approaches.

The purpose of the study was to determine the structure, compliance to antihypertensive pharmacotherapy in patients with arterial hypertension of the third degree in the conditions of Semey and the frequency of achieving target BP. The study included 618 patients with hypertension III degree. The age of patients ranged from 38 to 77 years (mean age - 61,2 ± 2,7 years). Among the surveyed men was -353, women - 265. Carried out an analysis of medical records and patient survey to determine the structure of antihypertensive therapy, compliance to it and the existing violations preparations reception mode. Was revealed prevalence in the appointment’s structure the combinations of antihypertensive drugs (46.0%) and fixed combinations (29.0%). Monotherapy performed more frequently with beta-blockers and calcium channel antagonists. It revealed the greatest compliance to the use of fixed combinations of drugs and most high clinical efficacy of antihypertensive therapy options.

Aortic valve stenosis is the most common valvulopathy in developed countries. Transcatheter aortic valve implantation (TAVI) is a therapeutic alternative in symptomatic patients at high or prohibitive perioperative risk. Predilatation by balloon aortic valvuloplasty (BAV) under rapid ventricular pacing (RVP) has been a routine part of TAVI. However, both RVP and BAV carry substantial risks and an increasing number of interventional centers are performing TAVI without predilatation (direct TAVI). A transient decrease of left ventricular function and elevated markers of myocardial injury after TAVI with predilatation were observed in previous studies. In this study, we investigated whether direct TAVI was associated with a similar increase in cardiac biomarkers and decrease in ejection fraction in a cohort of our patients.Consecutive patients undergoing TAVI without predilatation using a self-expanding system at a single center between April 2013 and December 2015 were followed up for one year and were retrospectively analyzed regarding mortality, safety and efficacy endpoints as well as common laboratory and echocardiographic parameters.A total of 164 patients (83±6 years; 56% female) were included in the analysis. According to the Valve Academic Research Consortium 2 (VARC-2) criteria the technical success rate was 96.3% and 89.1% of patients remained free of a combined safety endpoint at 30 days. Mortality rates at 30 days and 1 year were 3.0% (N.=5) and 10.4% (N.=17), respectively. TAVI without predilatation was highly effective in lowering aortic valve peak velocity from 4.4±0.6 m/s before to 1.7±0.5 m/s (P0.01), and mean pressure gradient across the valve from 48.7±15.1 mmHg to 8.3±4.5 mmHg (0.05). Left ventricular function remained unaltered after the intervention (51±10% prior to TAVI and 51±9% post TAVI), whereas high sensitive troponin T (hs-TnT), a well-established marker for myocardial injury, increased significantly from 26 ng/L (interquartile range=18.00-44.00) to 119 ng/L (interquartile range=73.25-166.00, P0.001) during this time. Notably, an increase in the plasma levels of hs-TnT15 times the upper limit of normal was associated with mortality both one month and one year after TAVI.TAVI without predilatation is feasible, safe and effective for aortic valve replacement in symptomatic patients with severe aortic stenosis who are at high perioperative risk. In contrast to a cohort of patients who underwent TAVI with predilatation previously published by another center, our patients did not suffer from transient impairment of left ventricular function. As a marker of myocardial injury, hs-TnT showed a less pronounced increase than reported previously. This might be a marker for a prognostic benefit as hs-TnT has been shown to be a strong predictor of outcome in patients undergoing TAVI. We conclude that direct TAVI is a less invasive option involving less myocardial stress.

Background: Atrial fibrosis or fatty deposition is known to increase the propensity for the development of atrial fibrillation (AF). Apart from the pulmonic veins, the interatrial septum (IAS) might play a role in the maintenance of AF. In contrast to left atrial anatomy and adjacent veins, the IAS cannot be visualized in detail with computed tomography. Thus, preprocedural transesophageal echocardiography (TEE) may provide important morphologic information beyond exclusion from atrial thrombi. Methods: The study comprised 108 consecutive patients (mean age 60 ± 11 years; 98 men). AF was paroxysmal in 91 (84%) and persistent in 17 (16%) patients. We investigated the morphological characteristics of the IAS by TEE in patients who underwent radiofrequency ablation of AF. Results: The IAS was structurally abnormal in 46 (43%) patients, showing the following echocardiograhic findings: atrial septal hypermobility or aneurysm (n = 27) associated with a patent foramen ovale (PFO) (n = 11) or with a small atrial septal defect (ASD) (n = 2), a septal flap associated with a PFO or an ASD (n = 8), and an abnormally thickened IAS (n = 12). A thrombus in the left atrial appendage was discovered in only 2 (2%) patients. Conclusions: A structurally abnormal IAS was diagnosed in nearly half of the patients undergoing ablation therapy for AF. The information obtained by TEE is mandatory to exclude left atrial thrombi prior the ablation procedure. Moreover, detailed knowledge of morphologic characteristics of the IAS facilitates an optimized and safe performance of the transseptal puncture using long sheaths with large diameters. (Echocardiography 2013;30:402-406)

AIMS: Comorbidities pose a major challenge to screening, selection and follow-up of transcatheter aortic valve implantation (TAVI) patients as well as to the procedure itself. The aim of the present study was to assess cardiac and non-cardiac readmission rates besides clinical endpoint data in the first 50 patients of a single center TAVI programme. METHODS AND RESULTS: TAVI was performed using the transfemoral CoreValve system. Procedural success rate was 94%; intraprocedural mortality was 2%. 82% of the patients remained free of a combined safety endpoint at 30 days, and 76.1% remained free of a combined efficacy endpoint at six months (modified criteria of the Valve Academic Research Consortium). At six months, among all surviving patients, 10.3% had experienced readmissions for cardiac causes, and 43.6% had experienced readmissions for non-cardiac causes. Causes of non-cardiac readmissions showed a wide distribution over various medical disciplines, reflecting the high rate of comorbidities. Beyond six months until a predefined reference date (mean follow up 9.9 months), the probability of hospitalization fell by half (1.54 vs. 0.74 hospital days per patient per month), driven by a decrease of non-cardiac readmissions. Karnofsky score before and after TAVI yielded a significant and sustained improvement of performance status, as assessed retrospectively at reference date. CONCLUSION: The findings of the present study suggest that the high prevalence of comorbidities in high-risk TAVI patients results in a high rate of non-cardiac rehospitalizations during the first 6 months of follow-up. Despite this fact, improvement of global everyday performance following TAVI as perceived by the patients seems to be substantial.

ANAMNESE UND KLINISCHER BEFUND: Ein 29-jahriger, bisher gesunder Mann kam nach einem primar unkomplizierten gastroenteritischen Infekt wegen akuter Myalgien mit hochfebrilen Temperaturen zur stationaren Aufnahme. Innerhalb von 24 Stunden entwickelte sich ein lebensbedrohliches Zustandsbild mit einem katecholeminpflichtigen hamodynamischen Schockzustand und einer therapierefraktaren anhaltenden ventrikularen Tachykardie. UNTERSUCHUNGEN: Echo- und elektrokardiographische sowie laborchemische Befunde waren vereinbar mit einer fulminanten Myokarditis und einer akuten Myositis. Serologisch und bakteriologisch wurde in der Folge eine akute Infektion mit Salmonellen der Gruppe D nachgewiesen. THERAPIE UND VERLAUF: Unter konservativer supportiver Therapie kam es innerhalb von wenigen Tagen zu einer Konsolidierung des Zustandsbildes. Abgesehen von einem – histologisch gesicherten – Myositisrezidiv nach vier Wochen blieb der weitere Verlauf unkompliziert und es zeigte sich sowohl klinisch als auch echokardiographisch eine vollstandige funktionelle Remission. Dreieinhalb Jahre spater verstarb der Patient plotzlich. Histologisch fand sich eine umschriebene narbige Myokardfibrose. SCHLUSSFOLGERUNGEN: Eine fulminante Myokarditis stellt im Akutstadium eine lebenbedrohliche Erkrankung dar, die Prognose nach Ausheilung gilt aber als gut. In dem von uns dargestellten Fall sprechen viele Indizien fur einen Plotzlichen Herztod als Spatkomplikation einer fulminanten Myokarditis bakterieller Genese.

Transcatheter aortic valve implantation (TAVI) is a less invasive technique for the treatment of severe aortic stenosis in high-risk patients. Occurrence of conduction disturbances requiring permanent pacemaker (PPM) implantation after TAVI is frequently observed.The retrospective analysis comprised 153 patients (96 women, aged from 65 to 97 years) who underwent TAVI due to high-grade aortic stenosis. The aim was to evaluate the incidence of high-grade atrioventricular (AV) block after TAVI and the percentage of ventricular pacing and pacemaker (PM)-dependency at the first follow-up 6-8 weeks after implantation.Out of the 153 patients (age 81 ± 6 years) who underwent TAVI, 144 (94 %) had a transfemoral and 9 (6 %) patients a transapical approach. A PPM was implanted in 31 (20 %) patients, 24 (16 %) were implanted with the Medtronic CoreValve® and 7 (5 %) with the Edwards Sapien® valve (p = n.s.). Complete AV block was the indication in 21 patients (68 %), second-degree AV block in 1 patient (3 %), slow atrial fibrillation in 3 patients (10 %), new left bundle branch block (LBBB) plus sustained ventricular tachycardia (VT) in 1 patient (3 %), sick sinus syndrome in 2 patients (7 %), whereas in 3 patients (10 %) a PPM was inserted for safety reasons because of new LBBB and first-grade AV block. All of the nine patients (6 %) with a preexisting bundle branch block developed total AV block after TAVI. At follow-up PM-dependency (intrinsic rhythm 30 bpm) occurred in 11/30 patients (37 %), whereas an intrinsic rhythm 50 bpm was seen in 17 patients (57 %). At nominal device programming the percentage of ventricular stimulation (VP) during the short-term observation period was 60 ± 44 % in dual-chamber devices (N = 18), and 70 ± 36 % in single-chamber PPM (N = 5).The PPM implantation rate of about 20 % after TAVI is comparable to previously published data. The need for permanent pacing is linked to the valve type and preexistence of a right bundle branch block. At short-term more than half of the patients implanted with a device were not strictly PM-dependent, but presented an underlying intrinsic rhythm, indicating that temporary AV conduction disturbances may recover over time. This might justify a more conservative approach in some patients under watchful waiting. From another point of view, ventricular pacing at a regular or sensor-modulated rate may provide rhythm stability and chronotropy during the short-term period post-TAVI.

Transcatheter aortic valve replacement (TAVR) is a less invasive treatment option for patients that are deemed too high a risk for surgical aortic valve replacement (SAVR). The aim of this review is to evaluate the frailty tools currently being used in patients referred for TAVR.Using a literature search involving database search engines from CINAHL, PubMed, SAGE publications and European Society of Cardiology conducted from 2010 to the present, a critical evaluation of studies dealing with frailty assessment in patients referred for TAVR/SAVR is discussed.Eight studies met the criteria using frailty assessment in TAVR/SAVR patients. In all reviewed studies the impact of frailty on clinical outcome has been proved. Different instruments for measurements of frailty were used that have not been robustly evaluated. Frailty was defined differently and results may not be comparable. All reviewed studies used different cutoffs and scales and some a composite scoring system, although validity was limited.For frailty assessment implementation of validated standardized test protocols based on well-established assessment tools, covering all domains of frailty among TAVR centers is crucial for patient selection. Secondly, validated cutoffs and scoring systems are essential.