Search

The rate of transvenous lead extraction (TLE) is increasing, with an increasing rate of complex devices being implanted. TLE is now a routine part of cardiac device management and up-to-date data on the safety and efficacy of TLE with modern tools and techniques is essential to management decisions regarding noninfectious indications for lead extraction. We present a contemporary, prospective review of TLE at our high-volume cardiac center. All patients who underwent TLE from June 2016 to June 2019 were enrolled in our local database, and baseline clinical data, procedural information, and outcome data were collected. In total, 561 leads were explanted (n = 153) or extracted (n = 408) from 341 patients over the study period. Patients were predominantly male (71%), with a mean age of 65 ± 17 years. The most common indication for lead removal was lead failure (45.2%, n = 154), followed by infection of the pocket or device (29.3%, n = 100). In total, complete success was achieved in 96.4% (n = 541) leads, clinical success in a further 2.1% (n = 12), and failure only in 1.4% (n = 8). There was an overall complication rate of 0.9% (3/341) for major complications and 1.5% (5/341) for minor complications. There were no deaths. In conclusion, our data suggest that there are ongoing improvements in the safety profile and success rates of lead extraction undertaken by experienced operators. The major complication rate now is1%.

To compare the ability of cardiac magnetic resonance tomography (CMR) and transthoracic echocardiography (TTE) to predict the need for valve surgery in patients with chronic aortic regurgitation on a mid-term basis. 66 individuals underwent assessment of aortic regurgitation (AR) both in CMR and TTE between August 2012 and April 2017. The follow-up rate was 76% with a median of 5.1 years. Cox proportional hazards method was used to assess the association of the time-to-aortic-valve-surgery, including valve replacement and reconstruction, and imaging parameters. A direct comparison of most predictive CMR and echocardiographic parameters was performed by using nested-factor-models. Sixteen patients (32%) were treated with aortic valve surgery during follow-up. Aortic valve insufficiency parameters, both of echocardiography and CMR, showed good discriminative and predictive power regarding the need of valve surgery. Within all examined parameters AR gradation derived by CMR correlated best with outcome [χ2 = 27.1; HR 12.2 (95% CI: 4.56, 36.8); (p

Die Trikuspidalklappeninsuffizienz ist eine haufige Erkrankung und in Abhangigkeit von ihrem Schweregrad mit einer erhohten Morbiditat und Mortalitat verbunden. Haufigste Ursache ist eine sekundare/funktionelle Trikuspidalklappeninsuffizienz aufgrund einer unzureichenden Segelkoaptation. Oft ist die Trikuspidalklappeninsuffizienz asymptomatisch. Im fortgeschrittenen Stadium zeigen sich Symptome der Volumenuberlastung. Die Methode der Wahl zur Evaluation und Graduierung der Trikuspidalklappeninsuffizienz ist die Echokardiografie. Die konservative Therapie umfasst die Abklarung und Behandlung zugrundeliegender Ursachen, wie eine Linksherzinsuffizienz mit konsekutiver Drucksteigerung im kleinen Kreislauf. Symptomatisch empfiehlt sich eine balancierte diuretische Therapie, sowie bei Vorliegen eines pulmonalen Hypertonus die Therapie mit pulmonalvaskularen Vasodilatoren.

The clinical outcome of patients with severe primary and secondary mitral regurgitation (MR) and heart failure or significantly reduced left ventricular ejection fraction (LVEF) who underwent percutaneous mitral valve repair (pMVR) is yet not well known. This study compares midterm outcome of patients with severe left ventricular dysfunction (EF ≤30%) versus patients with slightly or moderately reduced or normal LVEF (EF30%) after pMVR. One hundred thirty-six consecutive patients were enrolled: 42 patients displayed severe left ventricular dysfunction, group 1 (logistic EuroSCORE I 27.7 ± 21.8%; secondary MR in 37 patients), and 94 patients displayed slightly or moderately reduced or normal LVEF, group 2 (logistic EuroSCORE I 17 ± 18.2%; secondary MR in 21 patients). The primary efficacy endpoint was death of any cause, repeat mitral valve intervention, and/or New York Heart Association class ≥III, which was reached in 31% of patients in group 1 versus 40% in group 2 (p = 0.719) at a median follow-up of 371 days. MR, graded by transthoracic echocardiography, was reduced in both groups (p0.001) and New York Heart Association class improved in each group (p0.001), with no differences between groups (p0.05). In conclusion, at midterm follow-up, the pMVR provided significant clinical benefits with comparable results achieved both in patients with significantly reduced and in patients with moderately reduced to normal LVEF. Thus, pMVR represents a feasible and effective treatment in high-risk patients who otherwise have limited therapeutic options and no safe option to reduce MR.

Objective To assess long-term outcome and parameters associated with poor and favorable outcome in patients with a left ventricular ejection fraction (LV-EF) ≤25% and severe mitral regurgitation (MR) after percutaneous edge-to-edge mitral valve repair (pMVR). Background There is no data on long-term outcome in this cohort of patients. Methods We analyzed all 34 patients with a LV-EF ≤25% and severe MR treated with pMVR in 2 university hospitals from 2009 to 2012. Results Mitral regurgitation could be successfully reduced to grade ≤2 in 30 patients (88%). Long-term follow-up (up to 5 years) revealed a steep decline of the survival curve reaching 50% already 8 month after pMVR. In contrast, estimated survival of the remaining patients showed a favorable long-term outcome. Patients deceased during the first year presented with higher right ventricular tricuspid pressure gradient (RVTG) (44.5 ± 8.4 mmHg vs. 35.2 ± 15.4 mmHg, P = 0.035) and worse RV-function (P = 0.014) prior to the procedure. One-year mortality of patients with pulmonary hypertension and depressed RV-function (n = 22) was very high (77%) compared to the remaining patients (n = 12, mortality rate of 0%, P = 0.0001). Conclusions Although pMVR lead to a successful reduction of MR in patients with a LV-EF ≤25%, 1-year mortality in this cohort was very high. However, a subgroup of patients showed a favorable long-term outcome after pMVR. Especially the right ventricular parameters sustained RV-function and absence of pulmonary hypertension—easily assessed with echocardiography—might be used to identify this subgroup and encourage pMVR in these patients.

Objective The aim of this study was to assess the impact of different access-site closure strategies, suture or closure device (Proglide, Abbott Vascular), on vascular and bleeding complications after percutaneous mitral valve repair (MitraClip, Abbott Vascular). Background Considering the high-risk profile in patients receiving percutaneous mitral valve repair, complications related to the large 24 Fr access sheath and its relation to the closure technique have not been evaluated so far. Methods and Results Between 2009 and 2015, 277 consecutive high-risk patients with severe mitral valve regurgitation (MR) underwent percutaneous mitral valve repair at our institution using Z-suture (n = 150) or closure device (n = 127) to close the access-site. Duplex sonography was performed in all patients. The primary endpoint was access-site related complications according to the Valve Academic Research Consortium (VARC) criteria. Secondary outcomes were the incidence of bleeding complications and mortality. Access-site related VARC2 major and minor complications were comparable after closure with Z-suture or closure device (2,7% vs 3.1%, P = 0.81 and 15,3% vs 15.7%, P = 0.92). Three patients (2%) in the suture and four patients (3.1%) in the closure device group experienced unplanned endovascular intervention at the access site. Access-site related major bleeding was observed in 4 (2.7%) suture and 4 (3.1%) closure device treated patients (P = 0.81). No access site related mortality occurred. Conclusion Both Z-suture and closure device use after percutaneous mitral valve repair are feasible and safe. However, there is no benefit of one strategy over the other according to VARC2 major and minor complications.

Aims To evaluate the characteristics and clinical outcome of patients with new formation of left ventricular (LV) thrombus after percutaneous edge-to-edge mitral valve repair. Methods and results Between 2009 and 2012 we intended to treat 150 patients with severe mitral regurgitation (MR) with percutaneous edge-to-edge mitral valve repair in our centre. Post-procedural transthoracic echocardiographic examinations scheduled during the hospital stay revealed the new formation of LV thrombi in three out of 150 patients. All three patients suffered from end-stage systolic heart failure with a LV ejection fraction (LVEF) below 20% and were successfully treated in terms of MR reduction (reduction of at least two MR grades). No thrombus formation was observed in patients with a LVEF >20% treated in our centre (a total of 136 patients). The frequency of new LV thrombus formation in the cohort of patients with a LVEF ≤20% treated in our centre was 21% (three out of 14 patients). Conclusions New formation of LV thrombus was detected in patients with severely depressed LVEF (≤20%) after successful reduction of MR following percutaneous edge-to-edge mitral valve repair. This phenomenon could be a play of chance, but percutaneous edge-to-edge mitral valve repair using the MitraClip¨ system is a new procedure. Special care is needed when performing new procedures, and the unexpected post-procedural finding of LV thrombus formation in approximately 20% in this cohort is worth reporting.

Background Infarct size is an important predictor of cardiac risk after acute myocardial infarction. The established modality for its assessment is Tc99m-Sestamibi Single-photon emission computed tomography (SPECT). In recent years, data are emerging demonstrating that scar size as assessed by late gadolinium enhancement in cardiovascular magnetic resonance imaging (CMR) as well as the presence of microvascular obstruction (MO) may also provide prognostic information, however, so far no direct comparisons of both modalities have been reported. Methods We retrospectively analysed patients ( n = 281) with acute ST-elevation myocardial infarction and primary angioplasty who underwent Tc99m-Sestamibi-SPECT and CMR on a 1.5 T scanner at a median of 4.3 (IQR: 3.7–5.1) and 4.9 (IQR: 4.1–5.9) days after the acute event, respectively. The primary endpoint of the study was a composite of all-cause mortality, recurrent myocardial infarction and congestive heart failure requiring hospitalization. Results During a median follow-up of 3.0 (IQR: 2.0–4.5) years, 24 events occurred. The best predictor was MO ( P < 0.0001), followed by infarct size by CMR ( P = 0.0043) and infarct size by SPECT ( P = 0.012) (all P -values corrected for clinical risk). In a multivariate model including clinical and periprocedural parameters, MO remained the only significant predictor in addition to clinical risk. Conclusions The extent of MO as determined by CMR has an excellent prognostic value in predicting cardiac events following acute myocardial infarction and may be used as an alternative to infarct size assessment by Tc99m-Sestamibi-SPECT.

There is little consensus on optimal atrioventricular (AV) and ventricular-to-ventricular (VV) intervals in cardiac resynchronization therapy (CRT). The aim of this study was to examine a novel combination of Doppler echocardiography (DE) and three-dimensional echocardiography (3DE) for individualized AV- and VV-interval optimization compared to conventional electrocardiogram (ECG) optimization.In this double-blind, randomized controlled trial, 77 patients (male: 57, age: 68 ± 10 years) with severely reduced ejection fraction (EF), New York Heart Association (NYHA) class III or IV, and wide QRS complex (>120 ms) have been included. Patients were randomized to either AV- and VV-interval optimization using DE and 3DE (group 1, n = 39) or ECG (group 2, n = 38). 3DE was performed in all patients for the evaluation of left ventricular (LV) dimensions, EF and systolic dyssynchrony index (SDI), and NYHA class obtained before CRT and after 3 months. Primary endpoint of the study was clinical response to CRT, defined as a reduction of NYHA class by>=1 score. Secondary endpoints were change of EF, LV volumes, and SDI.There were significantly more responders in group 1 (82%) than in group 2 (58%, P = 0.021). Similarly, group 1 showed a larger increase in EF (7.0 ± 6.0% vs 3.4 ± 5.6%, P = 0.015) and a more pronounced reduction of SDI (-4.5 ± 5.9% vs -1.5 ± 5.6%, P = 0.039) than group 2.Compared with conventional ECG optimization, this novel echocardiographic optimization protocol resulted in a significantly higher response rate, improved LV systolic function, and may be used to select the optimal AV and VV intervals in CRT.

Single leaflet clip attachment (SLA) is a prevalent complication in percutaneous edge-to-edge repair of the mitral valve, leading to the recurrence of significant mitral regurgitation. The objective of this retrospective analysis was to evaluate a novel 3-D transoesophageal echocardiographic method for the assessment of clip attachment to the mitral leaflets.We analysed a total of 87 patients treated for symptomatic mitral regurgitation. In 47 patients, clip attachment to the leaflets was assessed by conventional 2-D transoesophageal echocardiography supported by biplane TEE images (biplane TEE group). In 40 patients, clip attachment to the leaflets was assessed by the intraprocedural 3-D volume method in addition to the conventional method (volumetric TEE group). The primary endpoint was defined as clip complications consisting of SLA and clip displacement at any time after clip implantation. Clip complications occurred in nine patients (19.1%) in the biplane TEE group and in two patients (5%) in the volumetric TEE group (p=0.06). Regarding the grade of mitral regurgitation, in the follow-up period we observed a more pronounced deterioration in the biplane TEE group than in the volumetric TEE group.These findings suggest that the additional use of 3-D volumetric transoesophageal echocardiography for the assessment of clip attachment to the mitral leaflets may contribute to a reduced rate of subsequent clip complications.

Objectives This study sought to compare cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) for assessment of area at risk, scar size, and salvage area after coronary reperfusion in acute myocardial infarction. Background Myocardial salvage is an important surrogate endpoint assessing the success of coronary reperfusion in acute myocardial infarction. SPECT, the established modality for assessment of myocardial salvage, requires radiopharmaceutical injection before revascularization and 2 examinations. The combination of T2 and late enhancement imaging in CMR can assess myocardial salvage in 1 examination, but up to now, data comparing both modalities are very limited. Methods We analyzed 207 patients who were treated by primary revascularization in acute myocardial infarction and who underwent both SPECT and CMR for assessment of myocardial salvage. In CMR, T2-weighted turbo spin echo sequences for area at risk and contrast-enhanced inversion recovery gradient echo sequences were performed. Results Image quality was insufficient in 27 patients (13%). In the remaining 180 patients, mean area at risk was 29.4 ± 18.7% of the left ventricle (LV), and infarct size was 14.7 ± 16.9% LV, resulting in a mean salvage area of 14.9 ± 15.1% LV in SPECT, whereas in CMR, mean area at risk was 28.0 ± 14.5% LV, and infarct size was 16.0 ± 13.5% LV, resulting in a mean salvage area of 11.9 ± 12.3%. Results of both modalities correlated well for area at risk (r = 0.80), scar size (r = 0.87), and salvage area (r = 0.66, all p Conclusions Assessment of the salvage area by CMR using T2 and late enhancement imaging correlates well with the established modality of SPECT. CMR therefore may be an alternative to paired SPECT imaging for myocardial salvage assessment, but the contraindications of the modality and limitations in the established T2 imaging sequences currently cause a considerable rate of data loss.

Objectives: To determine predictors for long-term outcome in high-risk patients undergoing transcatheter edge-to-edge mitral valve repair (TMVR) for severe mitral regurgitation (MR). Background: There is no data on predictors of long-term outcome in high-risk real-world patients. Methods: From August 2009 to April 2011, 126 high-risk patients deemed inoperable were treated with TMVR in two high-volume university centers. Results: MR could be successfully reduced to grade

We first describe the implantation of a MitraClip (Abbott Vascular, Abbott Park, IL, USA) between 2 previously implanted MitraClips to treat recurrent mitral regurgitation (MR). An 82-year-old male patient presented with dyspnea New York Heart Association NYHA class III due to recurrent severe MR 18 months after primarily successful implantation of 2 MitraClips. The initial procedure was performed to treat severe MR due to prolapse and flail of the anterior leaflet and resulted in mild MR after implantation of 2 MitraClips. Concomitant diseases were persistent atrial fibrillation, moderate tricuspid valve regurgitation, and chronic kidney disease stage 3. Thus, the patient was not considered a suitable candidate for surgical treatment. Using fluoroscopic guidance, 2D- and 3D-transesophageal echocardiographies, we succeeded in placing a third clip between the previously implanted clips and reduced the severe MR to mild MR without increase in the mean gradient. No periprocedural complications were observed. Six months after the procedure the patient presented with mild MR and NYHA class I. Learning objective: Implantation of MitraClips offers the possibility of percutaneous mitral valve repair. It is feasible, safe, and effective to implant a 3rd MitraClip between 2 previously implanted MitraClips to treat recurrent mitral regurgitation between the clips.>

Numerous patients are treated with the MitraClip, although they do not fulfill the stringent inclusion criteria of the Endovascular Valve Edge-to-Edge Repair Study (EVEREST) trials. The outcome of those patients is not well known. Therefore, we compared the long-term outcome after MitraClip treatment between patients who matched (group 1) and did not match (group 2) the EVEREST criteria. One hundred thirty-four consecutive patients were treated from September 2009 to July 2012: 59 patients (44%) in group 1 versus 75 patients (56%) in group 2. Investigated end points were acute procedural success (for group 1 vs 2: 97% vs 95%; p = 0.694), all-cause mortality (28% vs 27%; p = 0.656), reintervention (RI) rate (11% vs 37%; p = 0.010), and improvement in mitral regurgitation (MR) (−1.3 ± 1 vs −1.5 ± 1, p = 0.221) and in New York Heart Association functional class (−0.7 ± 1 vs −0.9 ± 0.8, p = 0.253) during the follow-up of 33 months (27.9 to 38.3). The morphologic extent of a flail leaflet was an independent predictor for RI. In conclusion, although the overall outcome was comparable between both groups, recurrent symptomatic MR with need for RI was higher in group 2, mainly because of complex valve pathologies: especially flail width >15 mm and gap ≥10 mm. Improvements in the interventional strategy are warranted for reducing the need for RI in patients with primary MR.

Besides different risk profiles for cardiovascular events in men and women, several studies reported gender differences in mortality after acute myocardial infarction (AMI). As infarct size has been shown to correlate with mortality, it is widely accepted as surrogate marker for clinical outcome. Currently, cardiovascular imaging studies covering the issue of gender differences are rare. As magnetic resonance scar characterization parameters are emerging as additional prognostic factors after acute myocardial infarction, we sought to evaluate gender differences in CMR infarct characteristics in patients after acute myocardial infarction. We prospectively analyzed patients (n = 448) with AMI and primary angioplasty, who underwent contrast enhanced cardiac magnetic resonance (CMR) imaging on a 1.5 T scanner in median 5 [Galatius-Jensen et al. in BMJ 313(7050):137–140, (1996), Burns et al. in J Am Coll Cardiol 39(1):30–36, (2002)] days after the acute event. CMR scar size was measured 15 min after gadolinium injection. In addition presence and extent of microvascular obstruction (MVO) was assessed. A matched pair analysis was performed in order to exclude confounding by gender related co-morbidities and gender differences in established clinical risk factors. Matching process according to clinical risk defined by GRACE score resulted in 93 mixed gender couples. Women were significantly older than men (64.4 ± 11.9 vs. 60.5 ± 12.3, p = 0.03) and presented with a significantly better ejection fraction before angioplasty (48.9 ± 8.4 vs. 46.2 ± 8.9, p = 0.04). Infarct size did not differ significantly between women and men (13.5 ± 10.7 vs. 15.1 ± 11.8, p = 0.32). Size of MVO was significantly smaller in women than in men (0.48 ± 1.3 vs. 1.2 ± 3.0, p = 0.03). Comparing scar characterization between women and men with similar risk profiles revealed no gender differences in scar size. Size of MVO, however, was significantly smaller in women and might reflect better cardioprotective mechanisms in women. Whether these changes have prognostic implications has to be tested on a larger patient population.

Objectives This study sought to establish normal values for real-time 3-dimensional echocardiography (RT3DE)–derived left ventricular (LV) dyssynchrony index (LVDI) and determine its age dependency, and to compare dyssynchrony in patients with normal LV function and patients with dilated cardiomyopathy (DCM), with and without left bundle branch block (LBBB). Background Cardiac resynchronization therapy is known to be ineffective in one-third of patients with heart failure, highlighting the need for alternative techniques to assess LV dyssynchrony. Methods Datasets from RT3DE were analyzed to calculate LVDI using 16- and 17-segment models. First, 135 normal subjects were studied to establish LVDI abnormality threshold (mean + 2 SD) and to study the relationship with age. Then, 3 groups of patients (N = 16 each: DCM with and without LBBB, normal LV function with LBBB) were compared with 50 age-matched normal control subjects. Results In normal subjects, the 16-segment model resulted in a lower LVDI abnormality threshold than the 17-segment model (4.0% vs. 4.5%). In patients with normal LV function, LVDI was significantly lower than in those with DCM, irrespective of LBBB. Although LBBB resulted in a nearly 2-fold increase in LVDI in patients with normal LV function, its effects were nonsignificant in DCM. All patients with DCM and ejection fraction Conclusions Normal values established in this study resulted in indiscriminate diagnosis of abnormal dyssynchrony in all patients with reduced LV function. The value of RT3DE-derived LVDI in the evaluation of dyssynchrony in patients with reduced LV function needs to be critically reassessed because of the inability to accurately detect end-ejection in low-amplitude regional volume curves. Alternative indices of dyssynchrony need to be developed to address this limitation.

To assess long-term outcome and parameters associated with poor and favorable outcome in patients with a left ventricular ejection fraction (LV-EF) ≤25% and severe mitral regurgitation (MR) after percutaneous edge-to-edge mitral valve repair (pMVR).There is no data on long-term outcome in this cohort of patients.We analyzed all 34 patients with a LV-EF ≤25% and severe MR treated with pMVR in 2 university hospitals from 2009 to 2012.Mitral regurgitation could be successfully reduced to grade ≤2 in 30 patients (88%). Long-term follow-up (up to 5 years) revealed a steep decline of the survival curve reaching 50% already 8 month after pMVR. In contrast, estimated survival of the remaining patients showed a favorable long-term outcome. Patients deceased during the first year presented with higher right ventricular tricuspid pressure gradient (RVTG) (44.5 ± 8.4 mmHg vs. 35.2 ± 15.4 mmHg, P = 0.035) and worse RV-function (P = 0.014) prior to the procedure. One-year mortality of patients with pulmonary hypertension and depressed RV-function (n = 22) was very high (77%) compared to the remaining patients (n = 12, mortality rate of 0%, P = 0.0001).Although pMVR lead to a successful reduction of MR in patients with a LV-EF ≤25%, 1-year mortality in this cohort was very high. However, a subgroup of patients showed a favorable long-term outcome after pMVR. Especially the right ventricular parameters sustained RV-function and absence of pulmonary hypertension-easily assessed with echocardiography-might be used to identify this subgroup and encourage pMVR in these patients.

The purpose of this study was to determine microbubble responses to different pulse sequence schemes that exist on low mechanical index (MI) real-time perfusion imaging systems using either intravenous albumin-coated (Optison) or lipid-encapsulated (Definity) microbubbles. A tissue-mimicking phantom was created that permitted insonation of microbubbles at 3 cm (near field) and 9 cm (far field) from the diagnostic transducer face. Differences in effluent microbubble concentration were measured after they passed through vessels being insonified with pulse sequence schemes that transmitted alternating polarity (pulse inversion Doppler), alternating amplitude (power modulation), or both (contrast pulse sequencing) at a similar MI, frame rate, and transmit frequency. Normalized contrast signal intensity within a recirculating chamber was also measured in the near and far field. Pulse inversion Doppler produced less initial normalized contrast signal intensity and greater destruction rates than amplitude varying pulse sequence schemes like power modulation or contrast pulse sequencing at both the 0.1- and 0.2-MI settings. These differences indicate that the same MI setting on different real-time perfusion imaging techniques will produce different microbubble responses.

Die Prognose der Herzinsuffizienz hat sich in den letzten drei Jahrzehnten erheblich verbessert. Trotz dieser Fortschritte steigt die Pravalenz der Herzinsuffizienz stetig und Morbiditat und Mortalitat sind weiterhin hoch, sodass neuen und erganzenden therapeutischen Strategien eine immer grosere Bedeutung zukommt.

There is little consensus on optimal atrioventricular (AV) and ventricular-to-ventricular (VV) intervals in cardiac resynchronization therapy (CRT). The aim of this study was to examine a novel combination of Doppler echocardiography (DE) and three-dimensional echocardiography (3DE) for individualized AV- and VV-interval optimization compared to conventional electrocardiogram (ECG) optimization.In this double-blind, randomized controlled trial, 77 patients (male: 57, age: 68 ± 10 years) with severely reduced ejection fraction (EF), New York Heart Association (NYHA) class III or IV, and wide QRS complex (120 ms) have been included. Patients were randomized to either AV- and VV-interval optimization using DE and 3DE (group 1, n = 39) or ECG (group 2, n = 38). 3DE was performed in all patients for the evaluation of left ventricular (LV) dimensions, EF and systolic dyssynchrony index (SDI), and NYHA class obtained before CRT and after 3 months. Primary endpoint of the study was clinical response to CRT, defined as a reduction of NYHA class by ≥1 score. Secondary endpoints were change of EF, LV volumes, and SDI.There were significantly more responders in group 1 (82%) than in group 2 (58%, P = 0.021). Similarly, group 1 showed a larger increase in EF (7.0 ± 6.0% vs 3.4 ± 5.6%, P = 0.015) and a more pronounced reduction of SDI (-4.5 ± 5.9% vs -1.5 ± 5.6%, P = 0.039) than group 2.Compared with conventional ECG optimization, this novel echocardiographic optimization protocol resulted in a significantly higher response rate, improved LV systolic function, and may be used to select the optimal AV and VV intervals in CRT.

To prospectively assess the outcome of percutaneous edge-to-edge repair in patients with degenerative versus functional mitral regurgitation (MR).The optimal patient population eligible for percutaneous edge-to-edge repair has yet to be defined.We analyzed 119 patients treated by percutaneous edge-to-edge repair for symptomatic MR, 72 patients with degenerative and 47 patients with functional MR. The primary endpoints were defined as procedural success (MR grade reduction>=1 grade) as well as a composite endpoint defined as freedom from MR 3+ or 4+, mitral valve reintervention and death 12 months after clip implantation. In patients with successful clip placement we further analyzed MR grade, New York Heart Association (NYHA) functional class, distance in the 6 min walking test and left ventricular volumes 12 months after clip implantation.The primary success rate of all intended clipping procedures was 83.3% for degenerative and 89.4% for functional MR (P = 0.42). Regarding the composite endpoint we observed an event free survival of 59.7% in patients treated for degenerative MR and 63.8% in patients treated for functional MR (P = 0.73). We observed a highly significant reduction in MR grade as well as improvement in NYHA functional status in both groups 12 months after clip implantation. However, there was a more pronounced MR grade reduction in patients treated for degenerative MR compared with patients treated for functional MR.Percutaneous edge-to-edge repair of the mitral valve is feasible and comparably effective in patients with degenerative and functional MR.

This study sought to compare cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) for assessment of area at risk, scar size, and salvage area after coronary reperfusion in acute myocardial infarction.Myocardial salvage is an important surrogate endpoint assessing the success of coronary reperfusion in acute myocardial infarction. SPECT, the established modality for assessment of myocardial salvage, requires radiopharmaceutical injection before revascularization and 2 examinations. The combination of T2 and late enhancement imaging in CMR can assess myocardial salvage in 1 examination, but up to now, data comparing both modalities are very limited.We analyzed 207 patients who were treated by primary revascularization in acute myocardial infarction and who underwent both SPECT and CMR for assessment of myocardial salvage. In CMR, T2-weighted turbo spin echo sequences for area at risk and contrast-enhanced inversion recovery gradient echo sequences were performed.Image quality was insufficient in 27 patients (13%). In the remaining 180 patients, mean area at risk was 29.4 ± 18.7% of the left ventricle (LV), and infarct size was 14.7 ± 16.9% LV, resulting in a mean salvage area of 14.9 ± 15.1% LV in SPECT, whereas in CMR, mean area at risk was 28.0 ± 14.5% LV, and infarct size was 16.0 ± 13.5% LV, resulting in a mean salvage area of 11.9 ± 12.3%. Results of both modalities correlated well for area at risk (r = 0.80), scar size (r = 0.87), and salvage area (r = 0.66, all p0.0001).Assessment of the salvage area by CMR using T2 and late enhancement imaging correlates well with the established modality of SPECT. CMR therefore may be an alternative to paired SPECT imaging for myocardial salvage assessment, but the contraindications of the modality and limitations in the established T2 imaging sequences currently cause a considerable rate of data loss.

BACKGROUND: Post-implantation therapies to optimize cardiac resynchronization therapy (CRT) focus on adjustments of the atrio-ventricular (AV) delay and ventricular-to-ventricular (VV) interval. However, there is little consensus on how to achieve best resynchronization with these parameters. The aim of this study was to examine a novel combination of doppler echocardiography (DE) and three-dimensional echocardiography (3DE) for individualized optimization of device based AV delays and VV intervals compared to empiric programming. METHODS: 25 recipients of CRT (male: 56%, mean age: 67 years) were included in this study. Ejection fraction (EF), the primary outcome parameter, and left ventricular (LV) dimensions were evaluated by 3DE before CRT (baseline), after AV delay optimization while pacing the ventricles simultaneously (empiric VV interval programming) and after individualized VV interval optimization. For AV delay optimization aortic velocity time integral (AoVTI) was examined in eight different AV delays, and the AV delay with the highest AoVTI was programmed. For individualized VV interval optimization 3DE full-volume datasets of the left ventricle were obtained and analyzed to derive a systolic dyssynchrony index (SDI), calculated from the dispersion of time to minimal regional volume for all 16 LV segments. Consecutively, SDI was evaluated in six different VV intervals (including LV or right ventricular preactivation), and the VV interval with the lowest SDI was programmed (individualized optimization). RESULTS: EF increased from baseline 23±7% to 30±8 (p

This study sought to establish normal values for real-time 3-dimensional echocardiography (RT3DE)-derived left ventricular (LV) dyssynchrony index (LVDI) and determine its age dependency, and to compare dyssynchrony in patients with normal LV function and patients with dilated cardiomyopathy (DCM), with and without left bundle branch block (LBBB).Cardiac resynchronization therapy is known to be ineffective in one-third of patients with heart failure, highlighting the need for alternative techniques to assess LV dyssynchrony.Datasets from RT3DE were analyzed to calculate LVDI using 16- and 17-segment models. First, 135 normal subjects were studied to establish LVDI abnormality threshold (mean + 2 SD) and to study the relationship with age. Then, 3 groups of patients (N = 16 each: DCM with and without LBBB, normal LV function with LBBB) were compared with 50 age-matched normal control subjects.In normal subjects, the 16-segment model resulted in a lower LVDI abnormality threshold than the 17-segment model (4.0% vs. 4.5%). In patients with normal LV function, LVDI was significantly lower than in those with DCM, irrespective of LBBB. Although LBBB resulted in a nearly 2-fold increase in LVDI in patients with normal LV function, its effects were nonsignificant in DCM. All patients with DCM and ejection fraction35% had abnormally high LVDI, likely as a result of low signal-to-noise ratio in low-amplitude regional volume curves hampering accurate determination of regional ejection time.Normal values established in this study resulted in indiscriminate diagnosis of abnormal dyssynchrony in all patients with reduced LV function. The value of RT3DE-derived LVDI in the evaluation of dyssynchrony in patients with reduced LV function needs to be critically reassessed because of the inability to accurately detect end-ejection in low-amplitude regional volume curves. Alternative indices of dyssynchrony need to be developed to address this limitation.

Background: Cross-sectional studies have shown that more than 50% of patients with congestive heart failure (CHF) have decreased bone mineral density (BMD). There is limited knowledge about the longitudinal changes of BMD and how to treat bone loss in patients with CHF. Methods: The present study was a prospective, longitudinal trial in which 33 male patients with CHF (ejection fraction (EF): 30±11%) were assigned to 1000 mg calcium supplementation or no supplementation. BMD was measured at the lumbar spine (LS) and the femoral neck (FN) by dual-energy X-ray absorptiometry at baseline and after 12 months. Results: Osteopenia (LS 33% and FN 36%) and osteoporosis (LS 15% and FN 6%) were frequently seen in these patients; 70% showed impaired renal function, 42% secondary hyperparathyroidism, and 33% hypogonadism. Bone resorption markers were strongly elevated and correlated negatively with the EF. Patients without calcium supplementation revealed a reduction of BMD (LS 1.7% and FN 1.9%) within 12 months. The fracture incidence was 6%. Patients with calcium supplementation also demonstrated a 6% fracture incidence and a decrease in BMD (LS 1.2% and FN 1.6%), which was not significantly different from the untreated group. Loss of BMD at FN was only seen in patients with impaired renal function. Conclusions: Patients with CHF demonstrate a progressive decrease in BMD when compared with age-matched healthy individuals. Increased bone resorption due to renal insufficiency with consecutive secondary hyperparathyroidism is a main reason for BMD loss in CHF. Calcium supplementation alone cannot sufficiently prevent the decrease in BMD.

Cocaine use is a major problem worldwide and there are numerous reports about cocaine-associated myocardial infarction. Nevertheless minimal data are available from randomised clinical trials to suggest evidence-based approaches to the management of cocaine-associated myocardial ischemia. Moreover, most reports have been limited to conservative management of cocaine-associated myocardial infarction. We report a case of a young male cocaine user with acute myocardial infarction, undergoing diagnostic coronary angiography and intravascular ultrasound revealing severe atherosclerosis, followed by successful stent implantation.

All current cardiac resynchronization therapy (CRT) devices allow manipulation of both atrioventricular (AV) delay and ventricular-to-ventricular (VV) interval with little consensus on the optimal setting. The aim of this study was to examine a novel combination of doppler echocardiography (DE) and