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BACKGROUND Defibrillator testing (DFT) is still used in selected patients to ensure adequate therapy. To do so, ventricular fibrillation is induced and terminated by the implanted cardioverter defibrillator (ICD). Studies have shown increases in neuronal damage markers without a measurable clinical effect in patients after defibrillator threshold testing with multiple shocks. OBJECTIVE The aim of this study was to measure clinical outcomes, neuronal damage parameters (NSE and S100), and intraoperative cerebral perfusion (Doppler, near infra-red spectroscopy [NIRS]) in patients undergoing single DFT after transvenous ICD implantation and comparing them to untested patients. METHOD We included 23 patients. Nine underwent surgery with a single DFT, 14 were not tested. Cognitive impairment was tested using the Mini-Mental-Status Test (MMST) and the DEMTECt 24 h prior and postsurgery. We also measured S100 and Neuron-Specific Enolase (NSE) at these timepoints. During surgery we measured medial cerebral artery velocity and cerebral tissue oxygen saturation (rSO2 ). RESULTS We found no significant differences between the patient groups except for a significant increase in mean arterial blood pressure and an increase in rSO2 after testing. One patient with cerebral vasculopathy had a significant increase in his NSE values without showing clinical symptoms. This patient also had low rSO2 measurements and a decrease in medial cerebral artery velocity after DFT, other than the other patients. CONCLUSION Single DFT did not lead to signs of neuronal damage or cognitive impairment except in one case with pre-existing cerebral vasculopathy. Therefore, our results support the use of DFT in carefully selected patients.

Graphical abstract Electronic supplementary material The online version of this article (10.1007/s00392-020-01756-0) contains supplementary material, which is available to authorized users.

BACKGROUND In the continuity equation, assumption of a round-shaped left ventricular outflow tract (LVOT) leads to underestimation of the true aortic valve area in two-dimensional echocardiography. The current study evaluated whether inclusion of the LVOT area, as measured by computed tomography (CT), reclassifies the degree of aortic stenosis (AS) and assessed the impact on patient outcome after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS Four hundred and twenty-two patients with indexed aortic valve area index (AVAi) of

Background Revascularization strategy in coronary artery bypass grafting (CABG) surgery usually depends on coronary dimension and stenosis severity. Little is known about the relation of preoperative evaluation of scarcely or invisibly chronic occluded coronary arteries (chronic total occlusion [CTO]) and revascularization rate or anastomosis quality. We aimed to evaluate the success rates of CTO revascularization in CABG surgery and determine the influence of coronary lumen visibility and collateralization in preoperative angiograms on revascularization rates, bypass blood flow, and target vessel diameter. Method Preoperative coronary angiograms were evaluated for 938 consecutive patients who underwent isolated CABG surgery between 2014 and 2016 and screened for occluded coronary arteries. The occluded vessels were scored for visibility using the Rentrop grading of collateral filling. Intraoperatively, dimensions of the occluded arteries were measured using conventional vessel probes, and anastomosis quality was assessed by transit time flow measurement. Results A total of 404 (43.1%) patients were identified with at least one CTO. Revascularization rates differed from 96.2% in the left anterior descending artery, to 85.0% in left circumflex artery-dependent vessels, and 78.8% in right coronary artery territory. Coronary visibility and grade of collateralization in the preoperative angiogram had no influence on intraoperatively measured coronary diameter. Bypass blood flow in grafts revascularizing CTOs lacking collateralization were not significantly lower than those grafts leading to CTOs with higher Rentrop scores. Conclusion Preoperative coronary assessment often differs from intraoperative findings. Our study confirms that even patients with scarcely collateralized CTOs and impaired visibility in the coronary angiogram have a high chance of complete revascularization during CABG surgery.

OBJECTIVES Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). METHODS A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value

Background Temporary transmyocardial pacing leads (TTPLs) represent an absolute contraindication to magnetic resonance imaging (MRI). The purpose of this study was to evaluate the safety and feasibility of MRI at 1.5 Tesla (T) using a transmit/receive (T/R) head coil in patients with TTPL. Methods TTPLs (220 cm, Osypka TME, Dr. Osypka GmbH, Rheinfelden, Germany) were implanted in a phantom and exposed to conditions of a 1.5 T brain examination using a T/R head coil. Temperature changes at the lead tip were continuously recorded. A total of 28 patients with TTPL and an urgent indication for a brain MRI underwent MRI at 1.5 T with vital sign monitoring. A T/R head coil was used to minimize radiofrequency exposure of the TTPL. Before and immediately after the MRI scan, TTPL lead impedance, pacing capture threshold (PCT), signal slope, and sensing were measured. Serum troponin I was determined before and after MRI to detect thermal myocardial injury. Results In vitro, the maximum temperature increase from radiofrequency-induced heating of the TTPL tip was Conclusions MRI of the brain may be performed safely at 1.5 T using a T/R head coil in case of an urgent clinical need in patients with TTPL and may be considered a feasible and safe procedure when appropriate precautionary measures are taken.

In der interventionellen Kardiologie ist eine stetig zunehmende Zahl an Patienten zu verzeichnen, die aufgrund ihres Alters und ihrer Komorbiditäten trotz eindeutiger prognoserelevanter Koronarstenosen nicht einer leitliniengerechten operativen Myokardrevaskularisation zugeführt werden können. Insbesondere Patienten mit relevanter, ischämisch bedingter Einschränkung der linksventrikulären Pumpfunktion profitieren von einer interventionellen Revaskularisation. Gefürchtete Komplikationen bei diesen Patienten sind die Kreislaufdepression bei prolongierter Koronarischämie, z. B. aufgrund länger andauernder Ballondilatationen, die akute Nierenschädigung aufgrund einer passageren Kreislaufdepression, Ischämie-getriggerte Herzrhythmusstörungen und inkomplette Revaskularisierung aufgrund einer Kreislaufinstabilität während der zumeist komplexen Prozeduren. Im Beitrag werden die Rationale, die Indikationen, die Datenlage, das praktische Vorgehen und die potenziellen Komplikationen dargestellt, die dem Konzept der geschützten Hochrisiko-Koronarintervention („protected percutaneous coronary intervention“, „protected PCI“) zugrunde liegen. A correction to this article is available online at https://doi.org/10.1007/s12181-017-0213-6

ZusammenfassungDie symptomatische hochgradige Trikuspidalklappeninsuffizienz hat eine hohe Mortalität und tritt häufig in Kombination mit linksseitigen Herzklappenerkrankungen auf. Die Behandlung der Trikuspidalklappeninsuffizienz erfordert eine genaue anatomische Kenntnis des Trikuspidalklappenapparats und für die Planung einer operativen oder interventionellen Behandlung ist eine genaue Evaluation der zugrunde liegenden Ätiologie unabdingbar. Minimalinvasive Behandlungsoptionen sind im Moment fast ausschließlich im Rahmen von Studien möglich. Erste klinische und prozedurale Erfahrungen mit den neuen Techniken sind vielversprechend. In diesem Übersichtsartikel werden die einzelnen Techniken und Optionen zusammengefasst.

An 83-year-old woman presented with progressive dyspnea in New York Heart Association functional class III. Echocardiography showed preserved left ventricular ejection fraction, severe mitral regurgitation (MR), and posterior mitral leaflet prolapse (segments P1 and P2) ([Figure 1A][1], [Online

Background Patients with acute myocardial infarction (AMI) are at high risk when undergoing emergency coronary artery bypass graft (CABG)-surgery. Their outcome remains poor despite increased use of extracorporeal membrane oxygenation (ECMO). We investigated the impact of timing for perioperative ECMO-support in these patients. Methods In this retrospective double-center study, we evaluated 201 patients with AMI undergoing CABG, dividing them into the following groups: No-ECMO (n = 101), preoperative ECMO (pre-ECMO, n = 6), intraoperative ECMO (ECC-ECMO, n = 67), and postoperative ECMO (post-ECMO, n = 27). We evaluated the impact of ECMO timing on postoperative mortality, organ function, and length of stay, comparing these to predicted outcome using different risk-scores. Results Post-ECMO patients showed lowest 30-day-survival (40.7%), while earlier ECMO-start was associated with better outcome (50.7% in extracorporeal circulation [ECC]-ECMO and 66.7% in pre-ECMO patients). On admission, only pre-ECMO and ECC-ECMO patients showed higher surgery- and intensive-care-unit (ICU)-related risk-scores. In pre- and ECC-ECMO patients, the first significant increase in lactate-levels (>4 mmol/L) was observed preoperatively, while this occurred 1 hour postoperatively in post-ECMO patients. Bilirubin was increased in all patients, decreasing after 3 and 12 days in pre- and ECC-ECMO patients, respectively, but only after 18 days in post-ECMO patients. Multiple ICU risk-scores did not discriminate survival-probability correctly. Only the ECMO-related survival after veno-arterial-ECMO-score correctly predicted the significantly lower survival in post-ECMO patients. Conclusion Our study shows that timely ECMO-support is associated with earlier bilirubin-downtrend and higher survival in patients with AMI after CABG. Lactate-increase greater than 4 mmol/L seems to be a helpful threshold to trigger the timely onset of ECMO-therapy, providing better survival.

AimsMore than mild paravalvular aortic regurgitation (pAR) negatively impacts prognosis after transcatheter aortic valve implantation (TAVI). "Newer generation" transcatheter heart valves (THVs) including Direct Flow Medical, Medtronic Evolut R, Boston Lotus, and Edwards SAPIEN 3 valve system promise to improve outcome by reducing the rate of TAVI-related issues such as pAR. Aim was to evaluate and compare the hemodynamic performance with AR index of "early" vs. "newer generation" THVs and its impact on outcome.Methods and resultsIn 805 patients undergoing TAVI, the degree of pAR was assessed using imaging modalities (angiography, echocardiography) and hemodynamic measurements (aortic regurgitation index, ARI ratio). Severity of pAR and outcome were assessed according to the VARC-2 criteria. 805 patients underwent TAVI with use of the CoreValve (n = 400), SAPIEN XT (n = 48), Direct Flow Medical (n = 38), Evolut R (n = 114), Lotus (n = 104), or SAPIEN 3 (n = 101) prosthesis. TTE post TAVI revealed that a total of 7.3% of the patients showed moderate/severe pAR. The occurrence of greater than mild pAR occurred less frequently in patients treated with "newer generation" THVs (pConclusionTAVI with use of "newer generation" THVs showed significantly reduced pAR and improved outcomes compared to "early generation" devices that could at least in part be explained by more favorable hemodynamics.

Die Mitralklappeninsuffizienz ist ein haufiges Vitium. Liegt eine bakterielle Endokarditis als Ursache vor, kann ein vorgezogener operativer Eingriff indiziert sein. Neben dem Ruckgang des mechanischen Klappenersatzes wird eine weitere Zunahme der Mitralklappenrekonstruktionen verzeichnet, der Zugang zum Herzen gelingt zunehmend minimalinvasiv. Dieser Trend setzt sich fort mit der Entwicklung von Operationsverfahren am schlagenden Herzen.

Die 2015 publizierten Endokarditisleitlinien der Europaischen Gesellschaft fur Kardiologie (ESC) geben praktische Hinweise zur Diagnostik und Therapie der Endokarditis. Veranderungen haben sich insbesondere ergeben durch Verbesserung in der Bildgebung (CT, nuklearmedizinische Bildgebung), die nun fest in die Leitlinien und die modifizierten Duke-Kriterien integriert sind. Therapeutische Entscheidungen werden verbessert durch die Einfuhrung von interdisziplinaren „Endokarditisteams“. Therapeutisch legt die erste randomisierte Studie eine fruhe Operation bei Patienten mit Embolierisiko nahe, auserdem konnten antimikrobielle Strategien optimiert werden.

AIMS Myocardial injury occurs frequently following transcatheter aortic valve implantation (TAVI). The aim of this study was to assess timing, predictors, and prognostic value of periprocedural myocardial injury and chronic troponin elevation after TAVI. METHODS AND RESULTS Two hundred and seventy-six patients (logistic EuroSCORE 26.6±17.1%) underwent transvascular TAVI. Troponin, CK-MB, and NT-proBNP levels were measured before and after TAVI (1 hr, 4 hrs, 24 hrs, 48 hrs, 72 hrs, seven days, three, and six months). Myocardial injury (according to VARC-2 recommendation defined as ΔTroponin ≥15x URL) occurred in 143/276 patients (51.8%) during the first 72 hours following TAVI. Use of a self-expanding prosthesis (p=0.02), coronary artery disease (p=0.04), higher left ventricular ejection fraction (LVEF) (p

Aims Transcatheter mitral valve-in-ring (TMVIR) implantation with transcatheter heart valve (THV) prostheses can be performed in patients with recurrent mitral regurgitation (MR) following annuloplasty. However, an oval configuration and sometimes the rigidity of surgical rings can often lead to suboptimal THV expansion, resulting in considerable paravalvular or central leakage. Therefore, our aim was to develop an annuloplasty ring that fully adjusts to THV implantation. Methods and results A three-dimensional annuloplasty ring was separated into four pieces at defined locations, the sections were reconnected with heat-shrinkable tubing and rearranged into the original shape. A non-tear stainless steel circular cord of defined length was inserted into the ring's sewing cuff to serve as a limiting structure for THV expansion. We implanted this ring in the mitral position into an isolated pig heart, deployed a THV into the ring, and investigated its function. Fluoroscopy showed that, upon THV deployment, the four breaking points of the ring separated as expected, and the ring expanded in a circular fashion to full expansion of the limiting cord. It securely anchored the THV to the ring, leaving no paravalvular gaps. Conclusions We developed an expandable mitral ring to which the THV attached without leakage. This may impact on the future design of annuloplasty rings. Further studies should evaluate the safety of increasing the perimeter of a mitral ring and its durability.

The use of left-ventricular (LV) hemodynamic support might facilitate high-risk percutaneous coronary interventions (PCI) in patients with complex coronary artery disease. The impact on outcome is a matter of ongoing debate. We assessed the outcome of high-risk patients who underwent protected PCI in comparison to patients who underwent unprotected high-risk PCI. One hundred and thirty nine patients underwent nonemergent high-risk PCI; 24 (17%) patients underwent protected PCI. To address selection bias, we performed a propensity score matched subanalysis. The primary end point was the occurrence of a major adverse cardiac event during the first year. Patients with protected PCI had a higher logistic EuroSCORE (logES) (protected PCI: 19% vs unprotected PCI: 12%; p = 0.01), a higher SYNTAX score (45 vs 36, p = 0.07), and significantly more often reduced LV function (40% vs 55%; p0.001). In protected PCI patients, complete revascularization was more often achieved (87% vs 58%, p = 0.007) without the occurrence of death at 30 days of follow-up (0% vs 4%, p = 0.31). After propensity score matching, patients who underwent protected PCI had a similar 1-year major adverse cardiac event rate compared with patients who underwent unprotected PCI (21% vs 17%, p = 0.67), despite significantly higher procedural complexity for example, more often complex left main bifurcation lesions (71% vs 29%; p = 0.004). In conclusion, 1-year outcome of patients who underwent protected PCI was not different from that in patients with less complex procedures without hemodynamic support, despite more complex coronary anatomy, a higher comorbidity burden, and more often reduced LV function.

Background Crystalloid priming is a cost-effective, free from immunological reactions, and independent from human plasma delivery. However, there is some debate on the negative impact of low plasma colloid pressure and higher incidence of systemic inflammatory response syndrome (SIRS). The aim of the study was to rule out any adverse effects of crystalloid priming on the postoperative outcome. Methods We investigated 520 consecutive patients, including emergencies, who had isolated on-pump coronary artery bypass grafting in 2009 by retrospective analysis in our clinic. Crystalloid priming (n = 294) was introduced as an alternative to albumin (n = 226). Reviewing patient charts and IT-based data generated a dataset of perioperative parameters. Results There were no differences with respect to demographical data and preexisting comorbidities between both groups. Despite equal perfusion times, more volume had to be substituted during extracorporeal circulation following crystalloid priming. However, this did not influence the inhospital outcomes. According to the definition of the “Sepsis-3 Guidelines,” the incidence of SIRS was similar. There was no difference in the need for a vasopressor treatment, and only transient higher serum lactate levels were found in the crystalloid group. The incidence of neurologic and organ-related adverse events, as well as 30-day mortality was comparable. Conclusion The use of crystalloid priming is safe in coronary artery bypass grafting surgery in adults. However, there might be a greater need for crystalloid fluids during surgery.

Aims The aim of this study was to assess the clinical value of biomarkers to identify TAVI patients at high risk for adverse outcome, to assess whether these biomarkers provide prognostic information beyond that of established clinical risk scores, and to assess whether a combined multi-marker strategy can improve clinical decision making. Methods and results In 683 TAVI patients, biomarkers reflecting various pathophysiologic systems were measured before TAVI. The primary endpoint was one-year all-cause mortality. Other outcomes were recorded according to the VARC-2 criteria. Thirty-day and one-year mortality was 2.9% and 12.0%, respectively. Non-survivors at one year had higher risk scores and increased median biomarker levels. Logistic EuroSCORE in combination with hs-CRP had the highest predictive value for 30-day (AUC 0.740 [95% CI: 0.667-0.812], p=0.1117) and one-year mortality (AUC 0.631 [95% CI: 0.569-0.693], p=0.0403). In multivariate regression analysis, logistic EuroSCORE in combination with hs-CRP showed the strongest association with one-year mortality. Combinations of increasing medians of logistic EuroSCORE results and hs-CRP levels allowed the stratification of the TAVI patients into subgroups with one-year mortality rates ranging from 6.6% up to 18.2%. Conclusions hs-CRP alongside the logistic EuroSCORE was an independent predictor of one-year all-cause mortality in TAVI patients. A combination of both might help to predict procedural risk and outcome better.

Left ventricular conduction disturbances (VCD) with or without need for pacemaker (PM) implantation are common after transcatheter aortic valve replacement (TAVR). Its effect on patients' functional recovery after TAVR is unclear.212 patients (Age 80.8 ± 6.4 years, logEuroscore 28.95 ± 17.37 %) underwent TAVR with the self-expanding CoreValve prosthesis and completed 9-month follow-up (FU). After TAVR 125 (59 %) patients were diagnosed with VCD. This group consists of 41 (19 %) patients with a new PM after TAVR, 33 (16 %) patients with PM prior TAVR and markedly increased ventricular stimulation rate, 48 (23 %) patients with new LBBB post-TAVR and three (1 %) patients with LBBB prior TAVR. After FU, the presence of VCD alone was associated with worse recovery of left ventricular ejection fraction (LVEF) (VCD: LVEFbaseline 51.7 ± 18.2 %, LVEFFU 53.9 ± 13.0 %; p = 0.8; noVCD: LVEFbaseline 53.8 ± 12.9 %, LVEFFU 63.4 ± 10.1 %; p 0.01) but had no impact on functional outcomes after TAVR (p 0.05). Especially patients with VCD caused by permanent RV pacing showed worse functional outcomes presenting with higher functional NYHA classes (p 0.05), and higher NT-proBNP levels (p 0.05). 20.4 % of patients with need for PM after TAVR remained in NYHA class ≥3, as compared to 5 % of patients without PM (VCD but no PM: 4.7 %, p 0.001; noVCD: 5.3 %, p 0.001). VCD with or without need for PM had no impact on survival after FU.The occurrence of VCD after TAVR is common and associated with unfavorable left ventricular functional recovery. However, only the combination of VCD with permanent right ventricular pacing has adverse impact on heart failure-related symptoms after TAVR.

Aims: Transcatheter aortic valve implantation for a failing surgical bioprosthesis (TAV-in-SAV) has become an alternative for patients at high risk for redo surgical aortic valve replacement (redo-SAVR). Comparisons between these approaches are non-existent. This study aimed to compare clinical and echocardiographic outcomes of patients undergoing TAV-in-SAV versus redo-SAVR after accounting for baseline differences by propensity score matching. Methods and results: Patients from seven centres in Europe and Canada who had undergone either TAV-in-SAV (n=79) or redo-SAVR (n=126) were identified. Significant independent predictors used for propensity scoring were age, NYHA functional class, number of prior cardiac surgeries, urgent procedure, pulmonary hypertension, and COPD grade. Using a calliper range of +/- 0.05, a total of 78 well-matched patient pairs were found. All-cause mortality was similar between groups at 30 days (6.4% redo-SAVR vs. 3.9% TAV-in-SAV; p=0.49) and one year (13.1% redo-SAVR vs. 12.3% TAV-in-SAV; p=0.80). Both groups also showed similar incidences of stroke (0% redo-SAVR vs. 1.3% TAV-in-SAV; p=1.0) and new pacemaker implantation (10.3% redo-SAVR vs. 10.3% TAV-in-SAV; p=1.0). The incidence of acute kidney injury requiring dialysis was numerically lower in the TAV-in-SAV group (11.5% redo-SAVR vs. 3.8% TAV-in-SAV; p=0.13). The TAV-in-SAV group had a significantly shorter median total hospital stay (12 days redo-SAVR vs. 9 days TAV-in-SAV; p=0.001). Conclusions: Patients with aortic bioprosthesis failure treated with either redo-SAVR or TAV-in-SAV have similar 30-day and one-year clinical outcomes.

Background The impact of coronary artery disease (CAD) and revascularization on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) has not been fully elucidated so far. Objectives To assess whether the degree of CAD influences the prognosis of patients undergoing TAVI. Methods Before TAVI, all patients underwent revascularization of the proximal vessels or the left main stem if indicated (stenosis ≥70% or 50%, respectively). In 666 patients, we calculated the baseline (bSS) and residual SYNTAX Score (rSS) prior to TAVI. In patients with revascularization, we determined the SYNTAX Revascularization Index (SRI=(1−(rSS/bSS))∗100). We also assessed the SYNTAX Score II (SS-II), combining anatomical and clinical variables. The primary endpoint was 3-year all-cause mortality. Results Higher baseline and residual SYNTAX Score were associated with increased 3-year mortality (no CAD 26.2%, low bSS 34.8%, high bSS 46.8%; p =0.001, respectively, no CAD 25.9%, low rSS 31.4%, high rSS 41.5%; p =0.01). The extent of revascularization represented by the SRI was not associated with outcome. The SYNTAX Score II was also associated with increased 3-year mortality. However, baseline and residual SYNTAX Score as well as SYNTAX Score II did not independently predict mortality. Conclusion The anatomic severity of CAD as assessed by the baseline and residual SYNTAX Score is associated with survival after TAVI. Coronary artery disease seems to reflect general comorbidity burden and is associated with a higher risk profile of the patient.

Background Transcatheter valve-in-ring strategies have been developed to treat recurrent mitral regurgitation (MR) after failing surgical annuloplasty. However, suboptimal THV expansion with consecutive paravalvular leakage (PVL) is a procedure-immanent issue. Methods A rigid, saddle-shaped ring was cut at four locations. The segments were reconnected with pull-springs, rearranged to the original shape, and covered with a sewing cuff. The length of the annuloplasty ring construct, including extended pull-springs, was defined by the perimeter of an appropriate THV. We deployed a Sapien XT within the new ring, expanded it to its maximum extent, and investigated the geometrical changes. Results Fluoroscopy confirmed oval, saddle-shaped ring before dilation. After THV implantation, the ring segments spread apart and pull-springs were stretched. The extended ring changed its configuration from “oval” to “round” and anchored the THV leaving no paravalvular or central gaps as potential source for PVL. Conclusion We developed an expandable annuloplasty ring that is perfectly concerted to THV implantation. This proof-of-concept study revealed no PVL and good oversizing ability that might impact future annuloplasty ring design. Further studies have to evaluate durability and device safety.

An 88-year-old male patient with history of ischemic dilated cardiomyopathy, previously treated with mitral valve replacement and percutaneous coronary revascularization, presented with worsening symptoms of heart failure, currently New York Heart Association class IV. Echocardiography revealed moderate-to-severe left-ventricular dysfunction (ejection fraction 35 %) and a degenerated 29 mm Carpentier-Edwards mitral bioprosthesis (Edwards Lifesciences, Irvine, CA, USA), with severe regurgitation (vena contracta 0.77 cm; PISA: 1.6 cm; effective regurgitant orifice area: 0.85 cm), Fig. 1, panel a, and a stenotic component (mean peak gradient 6.5 mmHg). Owing to a probably overestimated, but nevertheless high, surgical risk (logistic EuroSCORE 41.7 %) [1], the Heart Team opted for percutaneous antegrade transcatheter mitral valve-in-valve implantation (TMVIV), with an Edwards Sapien 3 device (Edwards Lifesciences, Irvine, CA, USA). After transseptal puncture, atrial septal dilatation with a 14 mm Osypka Balloon (Osypka AG, Rheinfelden-Herten, Germany) was performed at low pressures (panel b). We opted for a 14 mm balloon for because of previous TMViV cases that we used 10 and 12 mm balloons for septum predilatation and nevertheless were insufficient to allow valve passage after sheath introduction. Afterwards, valve positioning and implantation were carried out (panel c) over a pre-shaped stiff Confida wire (Medtronic, Minneapolis, MN, USA). No mitral stenosis or regurgitation was observed after the procedure (panel d). As expected, a significant iatrogenic atrial septal defect (ASD) was apparent after sheath removal. Even though the clinical significance of this defect is not clear [2], we performed the ASD closure as a safety measure, considering the risk of left-side thrombus embolization since we visualized thrombus formation in the right atrium on echocardiography during the procedure despite an activated clotting time above 200 s. Therefore, we utilized a 14 mm Amplatzer ASD-Occluder (St. Jude Medical, St. Paul, MN, USA), panel e, f. The patient was extubated immediately and on repeat echocardiogram predischarge, there was no evidence of thrombus in the cardiac chambers. We discharged the patient 5 days after the procedure with marked improvement in symptoms and on empirical dual antiplatelet therapy for 6 months. Valve-invalve procedures are an increasingly more utilized option for the treatment of failing bioprosthesis [3], including the latest Edward valve, the Sapien 3 [4]. Despite previous descriptions of antegrade TMVIV [5], most catheter-based mitral valve procedures are done through the transapical route [6]. Moreover, to our knowledge this is the first description of an antegrade TMVIV with an Edwards Sapien 3 valve with combined ASD closure. This case illustrates the feasibility and readiness of antegrade TMVI through transseptal access followed by ASD closure in the same procedure. & Felipe C. Fuchs fcfuchs@terra.com.br

The aims of this study were to determine plasma elevations of biomarkers of myocardial injury associated with transfemoral (TF) transcatheter aortic valve replacement (TAVR) and to evaluate their prognostic value.Increases in biomarkers of myocardial injury are a common finding after TAVR, but their clinical significance is unclear.In 756 consecutive TF TAVR patients, cardiac high-sensitivity troponin I (hsTnI) and creatine kinase MB (CK-MB) levels were measured at pre-defined time points to assess the occurrence of myocardial injury (defined as 15 times the upper reference limit for hsTnI [≥1.5 ng/ml] or 5 times the upper reference limit for CK-MB [≥18 μg/l]) during the first 72 h. The primary endpoint was all-cause mortality at 1 year.After uneventful TF TAVR, hsTnI was elevated in 51.6% and CK-MB in 7.4% of patients, respectively. Myocardial injury was associated with transcatheter heart valve (THV) type: patients who received the LOTUS THV more frequently had myocardial injury compared with those who received other THVs (LOTUS, 81.6%; Direct Flow Medical, 56.4%; CoreValve, 51.2%; Evolut R, 42.7%; SAPIEN XT, 40.4%; SAPIEN 3, 36.6%; p 0.001). Myocardial injury defined by hsTnI was not associated with adverse outcomes at 30 days (3.1% vs. 2.7%; p = 0.778) or 1 year (16.7% vs. 17.2%; p = 0.841). Likewise, a CK-MB increase was not associated with 30-day mortality (5.5% vs. 2.8%; p = 0.258) or 1-year mortality (16.4% vs. 17.3%; p = 0.856).Myocardial injury is common following TF TAVR. The extent of cardiac biomarker elevation depends on THV type but is not associated with adverse short- and long-term outcomes after uneventful TAVR.

Aims The current study includes all consecutive patients with advanced heart failure and cardiac resynchronization therapy (CRT) with an implantable cardioverter defibrillator (ICD) over a 10-year period in a tertiary referral centre. It aims at identifying independent risk factors for mortality during CRT-defibrillator (CRT-D) treatment. Methods and results This study includes 239 consecutive patients who had undergone implantation of a CRT-D system (ejection fraction 25.9 ± 8%; 139 patients with ischaemic, 100 patients with non-ischaemic cardiomyopathy). Enrolment took place between 2001 and 2010, resulting in a median follow-up of 43 ± 30 months. During follow-up, 59 patients (25%) died. An impaired baseline kidney function [hazard ratio (HR) 1.98; 95% confidence interval (CI) 1.7–3; P < 0.0001], appropriate ICD therapy during follow-up (HR 2.1; CI 1.1–3.4; P = 0.001), lack of beta-blocker therapy (HR 2.3; CI 1.6–3.8; P = 0.004), and intake of amiodarone (HR 2; CI 1.8–4.1; P < 0.0001) were identified as predictors of overall mortality. Conclusion This study demonstrates the benefit of beta-blocker therapy also in patients on long-term CRT-D treatment. It confirms the prognostic significance of impaired renal function and the occurrence of appropriate ICD therapies also in CRT-D patients. It argues for an intensified follow-up regimen and adjustment of heart failure treatment whenever these prognostic markers are identified in a patient treated with CRT-D.

Background: This study investigated the overall mortality and the incidence of ventricular tachyarrhythmia (VT) in 99 patients with nonischemic cardiomyopathy (NICM) and with an implantable cardioverter defibrillator (ICD) suffering from heart failure. Methods: We performed a stepwise regression model to identify independent risk factors for the occurrence of ventricular arrhythmias. Using a Cox regression model, independent risk factors for total mortality were evaluated and, subsequently, a Kaplan-Meier analysis was applied. The primary endpoint of this study was the identification of independent predictors of overall mortality and the incidence of malignant arrhythmias. Results: One hundred twenty-five VT (≥310 ms), 51 fast VT (between 310 ms and 240 ms), and 48 episodes of ventricular fibrillation (≤240 ms) were documented in 32 patients. Independent predictors of arrhythmias detected and treated by the ICD included female gender (odds ratio [OR] 3.4), lack of statin therapy (OR 3.5), and increased serum creatinine (OR 3.7). The Kaplan-Meier analysis showed no difference in survival between participants with or without VT. Total mortality was predicted by increased age (OR 2.3) and an impaired renal function (OR 1.9), independently. Conclusions: In this cohort of NICM patients with heart failure, female gender, lack of statin therapy, and increased creatinine represented independent risk factors for the incidence of malignant arrhythmias. Furthermore, renal insufficiency and age favored total mortality. Considering these results, impaired renal function might represent a valuable noninvasive tool to identify NICM patients who, despite ICD implantation, have the highest risk of mortality and therefore require a particularly thorough follow-up. (PACE 2011; 34:894–899)

Aims Malignant ventricular arrhythmias and inappropriate therapies represent unsolved problems in patients with implantable cardioverter/defibrillator (ICD) for primary prevention. This study focuses on the incidence of such therapies and thereby seeks to identify new predictors of adverse events to enhance risk stratification. Methods and results Ninety-four consecutive patients with mild-to-moderate heart failure (NYHA II-III) and depressed left ventricular function (≤35%) were followed for 34 ± 20 months. Two hundred and ninety-one malignant ventricular arrhythmias were documented in 51 patients (54%). Eighteen patients (19%) received inappropriate ICD therapies (e.g. atrial fibrillation, sinus tachycardia, etc.). Patients with malignant arrhythmia (1.34 ± 0.44 vs. 1.16 ± 0.4 mg/dL, P = 0.017) and patients suffering from inappropriate ICD therapies (1.54 ± 0.48 vs. 1.2 ± 0.38 mg/dL; P = 0.007) revealed a significantly worse renal function before ICD implantation than participants without any therapy. An increased serum creatinine at baseline (2 vs. 1 mg/dL; odds ratio (OR) 3.96; P = 0.02; 95% CI: 1.2-13.04) and NHYA class III compared with II (OR: 2.96; P = 0.02; 95% CI: 1.16-7.48) represent strong and independent predictors for the occurrence of ventricular arrhythmias. Moreover, an impaired renal function is identified as an independent risk factor for inappropriate therapies (OR: 5.6; P = 0.004; 95% CI: 1.72-18.22). Conclusion An impaired renal function and advanced heart failure before ICD implantation for primary prevention are identified as independent predictors for the incidence of appropriate ICD interventions. With regard to current guidelines and economical aspects, patients suffering from an impaired renal function or advanced heart failure seem to benefit most from ICD therapy.

Objectives The aim of this study was prospective investigation of silent and clinically apparent cerebral embolic events and neurological impairment after transfemoral aortic valve implantation (TAVI). Background TAVI is a novel therapeutic approach for multimorbid patients with severe aortic stenosis. We investigated peri-interventional cerebral embolism with diffusion-weighted magnetic resonance imaging (DW-MRI) and its relationship to clinical and serologic parameters of brain injury. Methods Cerebral DW-MRI was performed before, directly, and 3 months after TAVI with the current third-generation self-expanding CoreValve (Medtronic, Minneapolis, Minnesota) prosthesis. At the timepoints of the serial MRI studies, focal neurological impairment was assessed according to the National Institutes of Health Stroke Scale (NIHSS), and serum concentration of neuron-specific enolase (NSE), a marker of the volume of brain tissue involved in an ischemic event, were determined. Results Thirty patients were enrolled; 22 completed the imaging protocol. Three patients (10%) had new neurological findings after TAVI, of whom only 1 (3.6%) had a permanent neurological impairment. Of the 22 TAVI patients with complete imaging data, 16 (72.7%) had 75 new cerebral lesions after TAVI presumed to be embolic. The NIHSS and NSE were not correlated with DW-MRI lesions. Conclusions The incidence of clinically silent peri-interventional cerebral embolic lesions after TAVI is high. However, in this cohort of 30 patients, the incidence of persistent neurological impairment was low. (Incidence and Severity of Silent and Apparent Cerebral Embolism After Conventional and Minimal-invasive Transfemoral Aortic Valve Replacement; NCT00883285 )

Background:The performance of temporary pacing wires is still limited by capture and sensing problems. Fractal coating can enhance electrical properties and reliability. We therefore investigated fractal-laminated wires in comparison with conventional wires. Methods:In 21 patients two unipolar, fractal-coated pacing wires (fe) and one conventional bipolar electrode (se) were implanted in ventricular position. Afterward pacing threshold (V), R-wave sensing (mV), lead impedance (ohm), and slew-rate (mV/s) were measured. Loss of capture or sensing and dislocation was documented. fe wires were examined with energy dispersive x-ray diffraction (EDX)-analysis and scanning electrode microscopy (SEM). Results:Failure in pacing was less frequent in fe wires. Also fe leads had lower pacing thresholds at implantation (0.76 ± 0.15 V vs 1.51 ± 0.95 V, P< 0.0001) and afterward. Furthermore fe wires showed lower increase of pacing threshold/time (0.25 V/day vs 0.42 V/day). R-wave sensing and slew-rate values in the fe group on day of operation (5.81 ± 4.80 mV; 0.63 ± 0.71 V/s) were lower than in the se group (10.37 ± 6.89 mV; 1.85 ± 1.71 V/s P< 0.0001) and afterward. Nevertheless, decrease of amplitude/time was lower in fe wires (0.17mV/day vs 0.46 mV/day). fe wires always had lower impedance values. Conclusions:Lower pacing threshold and increase of threshold/time in fe wires indicate more reliable function. Initial lower sensitivity values are still not understandable and must be investigated. However, fe wires, constancy of sensing and impedance values was more stable, so fe epicardial wires can be recommended for safe and feasible use.

AIMS The aims of the study were to evaluate balloon post-dilation (BPD) and valve-in-valve (ViV) implantation for the reduction of paravalvular leakage (PVL) in patients undergoing transcatheter aortic valve implantation (TAVI) with use of the self-expanding CoreValve prosthesis and to assess whether the aortic regurgitation (AR) index can be used to quantify the reduction of PVL by these corrective measures. METHODS AND RESULTS Angiography and the AR index were used to evaluate the severity of PVL before and after corrective measures in patients suffering from more than mild PVL. Corrective measures were performed in 44.7% (101/226 patients): BPD was performed in 85 patients and ViV implantation in 16 patients, respectively. In 86% (87/101 patients), PVL reduction was successful (no or mild PVL). BPD increased the AR index from 19.1±11.0 to 25.9±5.8 (p

The aims of this study were to increase the discriminatory value of the aortic regurgitation index (ARI) for the assessment of paravalvular regurgitation (PVR) and to further elucidate the association between aortic regurgitation severity and mortality after transcatheter aortic valve replacement (TAVR).Hemodynamic parameters such as the ARI complement predominantly angiographically guided TAVR. However, the ARI depends on several baseline and periprocedural characteristics.The ARI was prospectively calculated before and after TAVR in 600 patients. The severity of PVR was assessed in all patients by angiography and echocardiography according to a 3-class scheme. To account for pre-procedural hemodynamic status, the ARI ratio was calculated as post- over pre-procedural ARI.Apart from the degree of PVR (β = -0.396, p0.001), pre-procedural hemodynamic status in the form of the ARI before TAVR (β = 0.227, p0.001) was associated with post-procedural ARI in multivariate regression analysis. The ARI ratio increased the specificity of post-procedural ARI alone for the prediction of both more than mild PVR and 1-year mortality from 75.1% to 93.2% and from 75.0% to 93.3%, respectively. Patients with post-procedural ARI values25 after TAVR had significantly increased 1-year mortality only when the ARI ratio was0.60 (50.0% vs. 26.3%, p = 0.001).The ARI ratio integrating pre- and post-procedural hemodynamic status increases the discriminatory value of post-procedural ARI. The ARI ratio, which reflects acute hemodynamic changes after TAVR, is useful to identify patients with negative outcomes.

Pacemakers, ICDs and stents are now playing a major role in cardiology. Again and again, however, there are reports of malfunctions and related deaths. Researchers have now compared the study results of cardiac high-risk products in the registration documents of the US Food and Drug Administration with peer-reviewed publications.

Background Aortic dissection is a severe and sophisticated disease that is often linked with a number of possible complications. Our study concerns with long-term outcome and quality of life (QoL) in acute aortic dissection type A (AADA) survivors. Methods From January 1999 until December 2006, 120 consecutive patients with AADA received an emergency operation. Of the total number of patients, 84 were males (70.0%) and 36 females (30.0%), mean aged 59.8 ± 12 years with a mean follow-up (FU) of 99.2 ± 6 months. Results Overall mortality was 39.1% during the observational period with a maximum of 156 months. SF-36 observation showed a significant decay in both Physical Component Summary (PCS) and Mental Component Summary (MCS) in FUII (PCS = 38.4) versus FUI (PCS = 43.4, p = 0.013). Conclusion With ongoing postoperative time, patients did not recover but instead have got worse in terms of QoL. The decrease in MCP and linked subscores is an underestimated factor in QoL and long-term outcome after AADA. This is especially true in younger patients, which are judged to compensate better than older patients.