Search

In high-risk patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) diabetes mellitus (DM) is a common comorbidity. It is known to increase the risk of arteriosclerosis and adversely affect morbidity, mortality for all types of cardiovascular disease, and post-procedural outcome after percutaneous and surgical procedures. Moreover, DM is known to facilitate the genesis of renal failure (RF). Pre-existing RF seems to increase the rate of acute kidney injury (AKI), which is a powerful short- and midterm predictor of mortality in patients undergoing TAVR. Therefore, the aim of the present study was to investigate the impact of DM on AKI, short- and midterm prognosis after TAVR, especially in patients with pre-existing RF.In 337(30%) of 1109 patients DM was documented. The incidence of RF at baseline (GFR60mL/min) was statistically similar in both patient groups (no DM vs. DM: 54% vs. 61%; p=0.057). Also, the incidence of AKI stage 3 was similar in all patients (no DM vs. DM: 1.6% vs. 1.8%; p=0.799). There were no significant differences regarding the procedure-related complications according to VARC-2 and mortality between patients neither with nor without DM. Even after differentiating patients according to baseline renal function, similar incidence of AKI and midterm mortality were documented.In patients undergoing TAVR, neither in case of preserved nor impaired renal function, we couldn't find any evidence for influence of DM on overall acute and midterm prognosis nor the incidence of AKI.

Background:MitraClip (MC) therapy is a percutaneous treatment option for surgical high-risk patients with both degenerative (DMR) and functional mitral regurgitation (FMR). We compared the acute he...

Significant functional mitral regurgitation (FMR) in elderly heart failure patients is increasingly being treated by MitraClip implantation. We sought to assess the prognostic implications of the intraprocedural assessment of vena contracta area (VCA) after MitraClip therapy in such patients.MitraClip therapy with intraprocedural assessment of VCA was performed in 97 heart failure patients (74±10 years; 66 men; left ventricular ejection fraction [LVEF] 31±12%; 93 patients in New York Heart Association [NYHA] functional Class III [n=59] or IV [n=34]; 86 patients with FMR severity 3+ [n=65] or 4+ [n=21]). Ninety-one patients (94%) were discharged with FMR severity ≤2+. During a median follow-up of 13.4 (interquartile range 4.6-21.1) months, 32 patients died. Multivariable Cox regression identified increasing age (HR [95% confidence interval]=1.05 [1.00-1.09], p=0.0395), a glomerular filtration rate50 ml/min/1.73 m² (HR=2.7 [1.3-5.7], p=0.0115), and post-MitraClip VCA25 mm² (HR=4.5 [2.1-9.5], p=0.0001) as independent predictors of mortality.In heart failure patients with FMR undergoing MitraClip therapy, increasing age, impaired baseline renal function and post-MitraClip VCA25 mm² are strongly associated with mortality. Post-MitraClip VCA may be used as intraprocedural guidance with respect to patients' long-term outcome.

Aims The study sought to assess outcomes of transcatheter mitral valve-in-valve implantation (TMVIV) for degenerated bioprostheses and transcatheter mitral valve-in-ring implantation (TMVIR) for failed annuloplasty rings according to access route and the Mitral Valve Academic Research Consortium (MVARC) criteria. Methods and results Twenty-four patients (72±13 years; eight men [33%]) underwent TMVIV (n=14) or TMVIR (n=10) for mitral regurgitation (MR; n=17) or stenosis (n=7) using balloon-expandable bioprostheses. Transapical (TA) access was chosen in 13, and transseptal (TS) access in 11 patients. MVARC technical success, device success and procedural success were 95.8%, 41.7% and 33.3%, respectively, with no differences between access routes. Cardiac output (CO) increased significantly by 1.1±0.8 l/min in TS patients, but not in TA patients (ΔCO=0.0±0.5 l/min; p=0.0051). Overall three-year survival was estimated at 57.6% (95% confidence interval: 33.9-81.3; TA 35.5% [5.2-65.9]; TS 90.9% [73.9-100]). Survival up to four years according to vascular access showed a clear benefit in patients treated transseptally (p=0.045). Conclusions Regardless of the access route, TMVIV/TMVIR was associated with high technical success yet impaired device success. In the long term, TA access had a significant adverse impact on survival.

Objectives The feasibility and outcomes of 35 consecutive patients subjected to eCPR in the tertiary cardiology center were investigated. Background While conventional cardiopulmonary-resuscitation (cCPR) often times achieves only mediocre outcomes extracorporeal cardiopulmonary-resuscitation (eCPR) increasingly shifts into the focus of interest. However, the scientific evidence for eCPR is sparse, particularly in the cardiological setting. Methods Retrospective chart analysis of 35 patients treated with eCPR between 01/2014 and 10/2015. Results The duration of cCPR until initiation of eCPR was 73.8 ± 37.6 min and resulted in an initial pH of 6.9 ± 0.2 and serum lactate level of 14.5 ± 4.8 mmol/L. About 62% (n = 22) of the patients suffered from out of hospital cardiac arrest (OHCA), 85% (n = 30) of the overall events were witnessed and bystander-CPR performed in 77% (n = 27) of cases. Cause of arrest was dominated by acute myocardial infarction (AMI, 71%), initial rhythm to a lesser degree by ventricular fibrillation/tachycardia (VF/VT, 57%). Almost all patients (n = 33, 94%) experienced return of spontaneous circulation (ROSC) after establishing extracorporeal life support (ECLS). In all 57% patients were successfully weaned from ECLS. Survival to discharge was 31% with predominantly good cerebral performance category (CPC 1-2). Survivors were more likely to receive bystander-CPR (P = 0.03) and the duration of cCPR until initiation of eCPR was significantly shorter (P = 0.004). Conclusions Our data proves the exceptional level of efficiency of eCPR particularly when Bystander-CPR has been initiated and there is a short duration of cCPR. © 2016 Wiley Periodicals, Inc.

AIMS To assess outcomes of TAVR as a rescue therapy in patients with cardiogenic shock due to acutely decompensated aortic stenosis. METHODS AND RESULTS Of 771 high-risk patients who underwent TAVR, 27 (3.5%; 78±9 years; 12 men) were treated emergently due to acutely decompensated aortic stenosis with cardiogenic shock. SAPIEN and CoreValve prostheses were implanted in 11 and 16 patients, respectively: the transfemoral access route was used in 25. Three patients died within 72 hours of successful valve deployment, and a further six died within a month, giving a 30-day mortality of 33.3%, which was significantly higher than in electively treated patients (7.7%, p

Aims Hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract obstruction frequently involves a systolic anterior motion (SAM) of the anterior mitral leaflet. We hypothesised that SAM could be a new target for MitraClip therapy. Methods and results Three patients with HOCM were chosen for MitraClip therapy, due to significant SAM with subsequent mitral regurgitation. Invasive haemodynamic studies (right heart catheterisation, simultaneous transaortic pressure recording, and administration of nitroglycerine) were performed before and after MitraClip implantation, and a six-week follow-up was undertaken. MitraClip implantation was successfully performed with significant reduction of mitral regurgitation and SAM in all patients. Basal peak gradients (before clip: 65±25.5 mmHg; after clip: 7.7±5.0 mmHg) as well as provoked pressure gradients (before clip: 145.3±8.1 mmHg; after clip: 23.2±7.6 mmHg) were significantly reduced after MitraClip implantation. Right heart catheterisation data did not reveal major changes. At six-week follow-up, all patients presented in a persistently improved clinical state (NYHA Class I-II) with insignificant residual MR and continuously reduced LVOT gradients. Conclusions This is the first catheter-based study targeting primarily a SAM in HOCM to reduce LVOT obstruction. The results prove the concept that SAM is more than an epiphenomenon in HOCM. Thus, SAM-induced obstruction might be a valuable target for the MitraClip.

Objectives The goal of this study was to assess procedural details and outcomes of repeat MitraClip therapy. Background MitraClip implantation is a safe and efficacious percutaneous approach to treat significant mitral regurgitation (MR). Methods Of 410 inoperable or high surgical risk patients treated with the MitraClip at our institution, 17 (4.1%) patients, as well as 4 patients initially treated at external institutions, underwent repeat MitraClip procedures. Mean age of the 21 patients (14 men [67%]) was 77 years; 15 patients (71%) had functional MR. Results Repeat procedures performed at a median of 6.3 months (range 0.7 to 34 months) after the index intervention were successful (discharge MR grade ≤2+) in 13 patients (62%), with a pronounced difference in success rate observed between the 13 patients with adequate leaflet insertion at the time of the repeat intervention and the 8 patients in whom loss of leaflet insertion (LLI) (leaflet tear/perforation or partial clip detachment) was present (11 of 13 [85%] vs. 2 of 8 [25%], respectively). The 21 patients were followed for a median of 8.5 (interquartile range: 2.3 to 18.6) months; 13 patients (62%), 8 with adequate leaflet insertion and 5 with LLI, died during follow-up. Conclusions Repeat MitraClip intervention for significant recurrent MR appears to be a viable therapeutic approach in patients in whom leaflet insertion into the MitraClip is not compromised. LLI is strongly associated with repeat procedural failure.

ObjectivesThis study sought to investigate the prevalence of abnormal von Willebrand multimers (AbM) in patients undergoing transcatheter aortic valve replacement (TAVR) and the impact of TAVR on the underlying factor variances.BackgroundAn association between the acquired von Willebrand syndrome (aVWS) and valvular aortic stenosis (AS) has been established in the past and surgical aortic valve replacement (SAVR) shown to lead to factor recovery. Prevalence and course of AbM in patients treated with TAVR though has not yet been described comprehensively.MethodsNinety-five consecutive patients underwent TAVR at our institution. Hemostaseologic testing was performed before and up to 1 week after TAVR. Transvalvular and right heart hemodynamics as well as bleeding episodes were recorded and analyzed with descriptive statistics.ResultsBaseline prevalence of AbM was 42% with an average high-molecular-weight multimer (HMWM) count of 16.2 ± 3.3%. Pressure gradients correlated significantly with the extent of HMWM deficiency (r = –0.63 [p < 0.0001]). Following valve implantation, HMWM increased proportional to the drop in mean pressure gradient and normalized in most of the patients. However, residual aortic regurgitation/leakage led to inferior HMWM recovery but prosthesis-patient mismatch (PPM) was rare and left HMWM uninfluenced. We saw no association of transfusion with AbM and 1-year mortality was unaffected by AbM.ConclusionsAbM in patients with AS undergoing TAVR is frequent. However, TAVR is capable of correcting AbM and therefore possibly aVWS in patients with AS. As opposed to SAVR, bleeding and transfusion requirement in TAVR patients was not associated with severe HMWM deficiency; PPM was rare and HMWM were uninfluenced by the procedure. Aortic regurgitation after TAVR adversely influenced HMWM recovery.

Transcatheter aortic valve implantation (TAVI) is a proven alternative to open heart surgery in elderly patients. Pulmonary hypertension (PH) is known as a significant risk factor in patients with severe aortic stenosis (AS) undergoing surgical aortic valve replacement. However, the prognostic impact of PH in high-risk patients undergoing TAVI is still unknown. The aim of this study was to gain more insight in the clinical outcome and mortality of patients with PH after TAVI.Between July 2009 and September 2012, a total of 439 patients were treated by TAVI in conjunction with a complete invasive right heart study at our institution. Patients were divided into two groups with regard to their pulmonary arterial mean pressure (PAMP) before TAVI (A: PAMP25 mmHg and B: PAMP ≥ 25 mmHg). Patients with baseline PH had a significantly higher logES (A: 19.40 vs. B: 28.17 %; p0.001) and were more frequently in NYHA functional class IV (A: 15.4 vs. B: 25.1 %; p = 0.013). Invasive right heart data demonstrated an immediate improvement after TAVI in patients with PH. Despite a similar clinical benefit among survivors, 30-day and 1-year mortality were higher in patients with PH (30-day mortality: A: 4.8 vs. B: 10.4 %; p = 0.021, 1 year mortality: A: 13.9 vs. B: 23.4 %; p = 0.014).Pulmonary hypertension is an independent risk factor for survival after TAVI. Nevertheless, TAVI leads to an acute improvement of nearly all invasively assessed variables in patients with PH, with a similar improvement in functional NYHA class compared to patients without PH, indicating a similar benefit among survivors.

Aims The Parachute® Ventricular Partitioning Device offers an additional strategy for heart failure patients with exclusion of the infarcted wall to decrease left ventricular volumes, myocardial work, and wall stress. The aim of the present study was to evaluate if Parachute implantation might influence acute haemodynamic and functional performance in patients with left ventricular aneurysm after anteroapical infarction. Methods and results Sixteen patients underwent a Parachute device implantation. Invasive right and left heart haemodynamic assessments as well as left ventricular analysis for evaluating left ventricle end-diastolic and end-systolic volumes, and regional ventricular function were analysed. After implantation a significant increase in stroke volume (+25.4%, P = 0.0005), stroke volume index (+26.5%, P = 0.0005), cardiac output (+25.8%, P

Background Transcatheter valve-in-valve (VIV) implantation has emerged as a novel treatment option in patients with degenerated aortic bioprostheses and high surgical risk. However, VIV implantation in small aortic bioprostheses using first generation TAVI devices has frequently resulted in high postprocedural gradients and small effective orifice areas. Recently, an updated version of the self-expandable Medtronic CoreValve prosthesis, which is particularly suitable for small aortic annuli, has become available. We report on the feasibility and early results of VIV implantation using this novel device in a series of patients with degenerated small aortic bioprostheses. Methods and Results 16 patients from two Hamburg hospitals (age range 72–92 years) underwent implantation of a 23-mm CoreValve Evolut (Medtronic, Minneapolis, MN, USA) transcatheter heart valve into failing aortic bioprostheses with internal diameters below 21 mm. All patients were considered high risk for surgical aortic valve replacement after evaluation by an interdisciplinary heart team mean (logistic EuroSCORE range 9.0–88%). Implantation was successful without relevant remaining aortic regurgitation or signs of stenosis and a marked reduction in postprocedural gradientswas observed in 14 out of 16 patients. The mean gradient was reduced from from 34 mm Hg (SEM 10 mm Hg) to 14 mm Hg (SEM 6 mm Hg). No major device- or procedure-related adverse events occurred during 30-day follow up and clinical improvement was observed. Conclusions Failing aortic bioprostheses with small internal diameters continue to be a challenging pathology for TAVI due to the risk of high residual gradients and small aortic orifice areas. This report provides first evidence that the 23-mm CoreValve Evolut, a novel self-expanding prosthesis, provides an improved treatment option in these specific patients due to its low profile which resulted in promising early results. © 2013 Wiley Periodicals, Inc.

Background There is accumulating evidence that up to 20% of the implanted devices after TAVI are associated with a significant degree of paravalvular leaks, which appear to be associated with a negative clinical outcome. Methods A total of 355 patients with severe aortic valvular stenosis (AVS) were treated by TAVI (Corevalve n = 222, Edwards Sapien n = 133). Survival, NT-proBNP and the grade of PVL were quantified up to 12 months after implantation. Results Technical success rate was 97.8%. Thirty-day mortality was 9.6%. Post-procedural transvalvular aortic regurgitation was seen only in a minority of cases (5%), whereas PVL were frequently observed (grade

Perkutane Herzklappeneingriffe haben in den vergangenen 10 Jahren die Behandlungsmoglichkeiten von Patienten mit erkrankten Herzklappen enorm erweitert. Neben einer Miniaturisierung im Bereich der Medizintechnik basiert der Erfolg perkutaner Verfahren zu einem grosen Anteil auf einer Weiterentwicklung der kardialen Bildgebung. Fur spezielle interventionelle Mitralklappeneingriffe hat insbesondere die periprozedurale Echokardiographie erst die Voraussetzung geschaffen. Dieser Ubersichtartikel beschreibt ihren Einsatz bei den aktuell klinisch etablierten Verfahren der MitraClip®-Implantation, des Verschlusses periprothetischer Leckagen und der Mitralklappenvalvuloplastie.

Background Histopathological analyses of debris captured by a cerebral protection system during transcatheter aortic valve replacement have been reported, but the origin of the captured debris was not determined and risk factors were not defined. Methods and Results Embolic debris was analyzed from 322 filters used in a dual‐cerebral‐filter protection system implemented during transcatheter aortic valve replacement for 161 patients (mean age 81 years, 82 male [51%], logistic EuroSCORE 19% [interquartile range 12–31%]). The debris capture rate was high, with debris from 97% of all patients (156 of 161). No differences by filter location were found (brachiocephalic trunk 86% [139 of 161], left carotid artery 91% [147 of 161]; adjusted P =0.999). Five prevalent types of debris were identified: thrombus (91%), arterial wall tissue (68%), valve tissue (53%), calcification (46%), and foreign material (30%). Female sex ( P =0.0287, odds ratio 1.364, 95% CI 1.032–1.812) and diabetes mellitus ( P =0.0116, odds ratio 1.474, 95% CI 1.089–2.001) were significant risk factors for embolic debris. Additional analysis showed significantly more valve tissue in patients with predilation ( P =0.0294). Stroke and transient ischemic attack rates were 0.6% each (1 of 161). Conclusion This study showed a high rate of embolic debris consisting of typical anatomic structures known to be altered in patients with aortic stenosis undergoing transcatheter aortic valve replacement. Female patients with diabetes mellitus have increased risk of embolic debris and should be protected by a cerebral protection system during transcatheter aortic valve replacement. Because valve tissue embolizes more often in patients with predilation, procedural planning should consider this finding. Both cerebral arteries (brachiocephalic trunk, left carotid artery) should be protected in the same way.

AIMS The aim of this study was to assess the feasibility and early outcomes of transcatheter aortic valve implantation (TAVI) in dysfunctional TAVI prostheses (redo TAVI). METHODS AND RESULTS Nineteen redo TAVI procedures were performed between October 2011 and November 2015 at two German centres. Mean age was 78 years, 13 (68%) were male, and the mean logistic EuroSCORE was 32%. Median time elapsed since index TAVI was 644 days (interquartile range 191-1,831). Failure mode of the index TAVI prosthesis was regurgitation (AR) in 16 patients (n=12 paravalvular AR, n=3 combined paravalvular/valvular AR, n=1 valvular AR) and stenosis in three patients. Device success was achieved in 89% (17/19). Median invasive post-interventional transprosthetic gradient was 3.0 mmHg. No severe prosthesis-patient mismatch (PPM) was observed. At one year, mean pressure gradient was 9±1.2 mmHg and no relevant PPM was documented in 90% of the cases. All-cause mortality at 30 days and one year was 11% and 33% (6/18, five non-cardiac deaths), respectively. Mean follow-up time was 404 days. CONCLUSIONS Redo TAVI appears to be feasible. Paravalvular regurgitation was the most common indication for a redo procedure. Rates of device success were high with low post-interventional gradients and no severe PPM. Good functional status of the prosthesis was maintained after 12 months, but mortality rates were high in this small comorbid patient population.

Objective Histological analyses of debris captured by a cerebral protection system (CPS) during transcatheter valve-in-valve (VIV) procedures have not been reported. Methods Fifteen consecutive patients with stenotic aortic (n=13) or mitral (n=2) surgical or transcatheter bioprostheses were treated with implantation of a transcatheter heart valve (THV) in the presence of a dual-filter CPS. Mean patient age was 75 years; mean logistic EuroSCORE was 31%. Filters were collected and histological assessment of debris was performed. Patients were followed clinically until discharge. Results Debris captured by either or both filters was detected in all patients. Acute thrombus was the most common type of debris, found in all patients, followed in frequency by arterial wall tissue (n=12 patients (80%)), calcification (n=11 (73%)) and valve tissue (n=9 (60%)). Less frequently found were organised thrombus (n=5 (30%)), foreign material (n=4 (27%)) and myocardium (n=2 (13%)). A median of 123 debris particles per patient was detected, with a trend towards a greater median number of particles collected in proximal filters (78 vs 39, p=0.065). The average maximum particle diameter was 88 (range 56–175) µm, with a median of 20 particles ≥150 µm. No stroke or transient ischaemic attack (TIA) had occurred by the time of discharge (mean 8 days). Conclusions Transcatheter VIV procedures were associated with the release of particulate debris into the cerebral circulation in all patients. The type of debris suggests that debris originates predominantly from arterial and valvular passage of the THV.

Objectives This study questioned whether transaxillary transcatheter aortic valve implantation (TAVI) is feasible as a true percutaneous approach using percutaneous closure devices. Background Transaxillary TAVI is gaining increasing acceptance as an alternative to the transfemoral route; however, the access has always been done via surgical cutdown so far. Methods Between August 2010 and September 2011, a total of 24 high-risk patients with severe aortic valvular stenosis underwent a percutaneous TAVI procedure by direct puncture of the axillary artery without surgical cutdown. For safety reasons and as a target for the puncture, a wire was advanced via the ipsilateral brachial artery. Moreover, a balloon was placed into the subclavian artery via the femoral artery for temporary vessel blockade before percutaneous vessel closure. Vascular closure was performed using either the ProStar XL system (Abbott VascularDevices, Redwood City, California) or 2 ProGlide systems (Abbott VascularDevices). Results The true percutaneous approach was successfully completed in all patients (14 left and 8 right axillary artery cases). Overall mortality at 30 days was 8.3%. Acute vascular closure device success was achieved in 17 patients (71%). Vascular closure device success rate was 100% for the ProGlide device and 37% for the ProStar device, respectively. Seven patients (29%) with failing closure devices were treated by endovascular stent graft implantation without the need for surgical repair. For the last 12 treated patients, direct closure was achieved in 11 patients. Conclusions Direct puncture of the axillary artery for TAVI is feasible and safe if a wire is placed into the subclavian artery via the ipsilateral brachial artery.

The feasibility and outcomes of 35 consecutive patients subjected to eCPR in the tertiary cardiology center were investigated.While conventional cardiopulmonary-resuscitation (cCPR) often times achieves only mediocre outcomes extracorporeal cardiopulmonary-resuscitation (eCPR) increasingly shifts into the focus of interest. However, the scientific evidence for eCPR is sparse, particularly in the cardiological setting.Retrospective chart analysis of 35 patients treated with eCPR between 01/2014 and 10/2015.The duration of cCPR until initiation of eCPR was 73.8 ± 37.6 min and resulted in an initial pH of 6.9 ± 0.2 and serum lactate level of 14.5 ± 4.8 mmol/L. About 62% (n = 22) of the patients suffered from out of hospital cardiac arrest (OHCA), 85% (n = 30) of the overall events were witnessed and bystander-CPR performed in 77% (n = 27) of cases. Cause of arrest was dominated by acute myocardial infarction (AMI, 71%), initial rhythm to a lesser degree by ventricular fibrillation/tachycardia (VF/VT, 57%). Almost all patients (n = 33, 94%) experienced return of spontaneous circulation (ROSC) after establishing extracorporeal life support (ECLS). In all 57% patients were successfully weaned from ECLS. Survival to discharge was 31% with predominantly good cerebral performance category (CPC 1-2). Survivors were more likely to receive bystander-CPR (P = 0.03) and the duration of cCPR until initiation of eCPR was significantly shorter (P = 0.004).Our data proves the exceptional level of efficiency of eCPR particularly when Bystander-CPR has been initiated and there is a short duration of cCPR. © 2016 Wiley Periodicals, Inc.

The goal of this study was to assess procedural details and outcomes of repeat MitraClip therapy.MitraClip implantation is a safe and efficacious percutaneous approach to treat significant mitral regurgitation (MR).Of 410 inoperable or high surgical risk patients treated with the MitraClip at our institution, 17 (4.1%) patients, as well as 4 patients initially treated at external institutions, underwent repeat MitraClip procedures. Mean age of the 21 patients (14 men [67%]) was 77 years; 15 patients (71%) had functional MR.Repeat procedures performed at a median of 6.3 months (range 0.7 to 34 months) after the index intervention were successful (discharge MR grade ≤2+) in 13 patients (62%), with a pronounced difference in success rate observed between the 13 patients with adequate leaflet insertion at the time of the repeat intervention and the 8 patients in whom loss of leaflet insertion (LLI) (leaflet tear/perforation or partial clip detachment) was present (11 of 13 [85%] vs. 2 of 8 [25%], respectively). The 21 patients were followed for a median of 8.5 (interquartile range: 2.3 to 18.6) months; 13 patients (62%), 8 with adequate leaflet insertion and 5 with LLI, died during follow-up.Repeat MitraClip intervention for significant recurrent MR appears to be a viable therapeutic approach in patients in whom leaflet insertion into the MitraClip is not compromised. LLI is strongly associated with repeat procedural failure.

Papillary muscle rupture is a rare but potentially lethal complication of acute myocardial infarction. We report a 77-year-old man who presented to the emergency department with dyspnea and nausea and acute onset of severe back pain 3 days earlier. Owing to rapid deterioration of his hemodynamic and respiratory situation, the patient was immediately transferred to the intensive care unit. Intubation and catecholamine support became necessary to stabilize hemodynamics. Echocardiography revealed severe mitral regurgitation due to a complete rupture of the posterior papillary muscle. Despite treatment extension to intraaortic balloon counterpulsation, the patient continued to be in cardiogenic shock. Because the patient was rejected for surgical intervention, he underwent successful emergency MitraClip (Abbott Vascular, Santa Clara, CA) implantation and was discharged from hospital in good clinical condition. This report suggests that MitraClip implantation is a safe and effective alternative treatment option in this devastating disorder.

AIMS Transcatheter mitral valve-in-valve implantation (TMViVI) for the treatment of failing mitral xenografts or recurrent mitral regurgitation after surgical ring implantation is an emerging therapy for patients in need of repeated mitral valve surgery. Despite the fact that these procedures have been shown to be feasible and effective, haemodynamic data after TMViVI are still limited in the literature. METHODS AND RESULTS Twelve patients (logES: 39.2±23.5%) were treated either by transapical (n=7) or transseptal (n=5) TMViVI, as a valve-in-valve (ViV, n=8) or valve-in-ring (ViR, n=4) implantation. Left atrial pressures (LAP), transmitral gradients and right heart haemodynamics (Swan-Ganz catheterisation) were studied before and after TMViVI. Procedural success was 100%, mitral regurgitation after TMViVI was mild in one, trace in five and absent in six patients. Thirty-day mortality was 0%. Left atrial pressures decreased significantly after valve implantation (before LAPmean/v-wave: 24.3/44.1 mmHg; after LAP/v-wave 15.9/22.1 mmHg; p

Transcatheter aortic valve implantation (TAVI) is an accepted alternative for patients with severe aortic valve stenosis who cannot undergo surgery. Acute kidney injury (AKI) is a serious complication in any invasive cardiovascular intervention. The objectives of the study were to determine (i) the influence of kidney function before TAVI and (ii) the impact of changes in kidney function after TAVI, including acute kidney injury (AKI), on mortality.A total of 540 patients undergoing TAVI were included. Patients were divided into three groups according to glomerular filtration rate (GFR) before TAVI (A: normal renal function i.e. GFR ≥60ml/min; B: impaired renal function i.e. GFR 30-59ml/min; C: severe impaired renal function i.e. GFR30ml/min). Multivariate analysis showed a significant impact of GFR on mortality (p0.0008). Subgroup analysis showed significant differences between the groups in 30-day (A: 5.4%, B: 9.0%, C: 25.0%) and 12-month mortality (A: 15.0%, B: 32.0%, C: 49%). Patients who had an increase in GFR after TAVI by more than 22% (p=0.0068) had an improved survival rate, whereas a decrease in GFR by more than 15% was associated with an increased mortality rate (p=0.0051). AKI occurred in 30 patients (5.6%), of which 22 patients (73.3%) died within 12months.Outcome is significantly related to pre-procedural kidney function. In addition, changes in kidney function after TAVI have a significant impact on mortality. Due to a very poor prognosis in patients with AKI, any effort to prevent this serious complication after TAVI needs to be taken.

The Parachute(®) Ventricular Partitioning Device offers an additional strategy for heart failure patients with exclusion of the infarcted wall to decrease left ventricular volumes, myocardial work, and wall stress. The aim of the present study was to evaluate if Parachute implantation might influence acute haemodynamic and functional performance in patients with left ventricular aneurysm after anteroapical infarction.Sixteen patients underwent a Parachute device implantation. Invasive right and left heart haemodynamic assessments as well as left ventricular analysis for evaluating left ventricle end-diastolic and end-systolic volumes, and regional ventricular function were analysed. After implantation a significant increase in stroke volume (+25.4%, P = 0.0005), stroke volume index (+26.5%, P = 0.0005), cardiac output (+25.8%, P 0.0001) and cardiac index (+25.9%, P 0.0001) was found. In addition to an increase in mean aortic (P = 0.0050) and pulmonary pressure (P = 0.0347), there were significant increases in stroke work index (P = 0.0003), left (P = 0.0015) and right (P = 0.0024) ventricular stroke work index as well as left and right cardiac work index (both P = 0.0001), while the remaining haemodynamic parameters remained unchanged. Left ventricular analysis showed an acute reduction of the left ventricular end-diastolic volume (-18.0%, P 0.0001) and left ventricular end-systolic volume (-26.3%, P 0.0001) and an increase in ejection fraction from 22.9 to 30.6% (+38.4%, P 0.0001). Most interestingly, the basal wall segments displayed an increased contribution to the left ventricular ejection fraction with increased wall motion in nearly all segments (except the apex region).The data demonstrate the acute haemodynamic efficacy of Parachute device implantation. The implantation of the device displays immediate significant left ventricular volume reduction leading to an acute improved right and left cardiac function, proving the concept of left ventricular partitioning.

In reply to the letter of Dr. Genereux and colleagues, we strongly agree with their continuative analysis of our data that in conjunction with their work on major late bleeding complications offer a substantiated hypothesis for the paravalvular leakage (PVL)-associated mortality after

Transcatheter valve-in-valve (VIV) implantation has emerged as a novel treatment option in patients with degenerated aortic bioprostheses and high surgical risk. However, VIV implantation in small aortic bioprostheses using first generation TAVI devices has frequently resulted in high postprocedural gradients and small effective orifice areas. Recently, an updated version of the self-expandable Medtronic CoreValve prosthesis, which is particularly suitable for small aortic annuli, has become available. We report on the feasibility and early results of VIV implantation using this novel device in a series of patients with degenerated small aortic bioprostheses.16 patients from two Hamburg hospitals (age range 72-92 years) underwent implantation of a 23-mm CoreValve Evolut (Medtronic, Minneapolis, MN, USA) transcatheter heart valve into failing aortic bioprostheses with internal diameters below 21 mm. All patients were considered high risk for surgical aortic valve replacement after evaluation by an interdisciplinary heart team mean (logistic EuroSCORE range 9.0-88%). Implantation was successful without relevant remaining aortic regurgitation or signs of stenosis and a marked reduction in postprocedural gradientswas observed in 14 out of 16 patients. The mean gradient was reduced from from 34 mm Hg (SEM 10 mm Hg) to 14 mm Hg (SEM 6 mm Hg). No major device- or procedure-related adverse events occurred during 30-day follow up and clinical improvement was observed.Failing aortic bioprostheses with small internal diameters continue to be a challenging pathology for TAVI due to the risk of high residual gradients and small aortic orifice areas. This report provides first evidence that the 23-mm CoreValve Evolut, a novel self-expanding prosthesis, provides an improved treatment option in these specific patients due to its low profile which resulted in promising early results. © 2013 Wiley Periodicals, Inc.

Several studies and registers such as EVEREST, ACCESS-EU and PILOT EUROPEAN SENTINEL showed safety and effectiveness of the MitraClip system. However, only limited data exists for patients with MR and severely reduced left ventricular (LV) ejection fraction (LVEF). We report our single-centre

Correlation of histopathologic findings of cerebral debris to computer tomography (CT) measured volume of calcium load (CL) captured by a cerebral protection system (CPS) during transcatheter aortic valve replacement (TAVR) have not been reported. In 74 patients undergoing TAVR, CT measured volume

Histopathologic analyses of debris captured by a cerebral protection system (CPS) during transcatheter aortic valve replacement (TAVR) have been reported but it was not possible to determine the origin of the debris nor to define risk factors. Embolic debris captured in 322 filters of a dual

Previous studies showed that patients with impaired left ventricular (LV) function and low-flow, low-gradient (LFLG) aortic stenosis (AS) are associated with high operative risk and poor long-term outcome after surgical aortic valve replacement. The aim of this study was to investigate the clinical

There is accumulating evidence that up to 20% of the implanted devices after TAVI are associated with a significant degree of paravalvular leaks, which appear to be associated with a negative clinical outcome.A total of 355 patients with severe aortic valvular stenosis (AVS) were treated by TAVI (Corevalve n = 222, Edwards Sapien n = 133). Survival, NT-proBNP and the grade of PVL were quantified up to 12 months after implantation.Technical success rate was 97.8%. Thirty-day mortality was 9.6%. Post-procedural transvalvular aortic regurgitation was seen only in a minority of cases (5%), whereas PVL were frequently observed (grade:1+ in 58.2%, ≥1-2 in 33.9%, and ≥2 in 7.9%). There was a clear relation-ship between PVL and adverse outcome (P 0.001). After a transient increase, NT-proBNP showed a significant decline. Interestingly, a PVL ≥2+ was associated with a much higher rise in NT-proBNP compared to the other groups (P 0.01), and a post-procedural increase in NT-proBNP by more than 1640 ng L(-1) within 5 days was associated with a significant increase in rate of death (P 0.01).TAVI is an efficient treatment option for high-risk patients with severe AVS. The incidence of PVL is an inacceptable clinical problem. Serial measurement of NT-proBNP can be used for risk-stratification in patients with a significant PVL. In general, PVL graded ≥2+ is associated with a dramatically increased 6-month mortality. Therefore, any action to reduce paraprosthetical regurgitation is highly recommended.

This study questioned whether transaxillary transcatheter aortic valve implantation (TAVI) is feasible as a true percutaneous approach using percutaneous closure devices.Transaxillary TAVI is gaining increasing acceptance as an alternative to the transfemoral route; however, the access has always been done via surgical cutdown so far.Between August 2010 and September 2011, a total of 24 high-risk patients with severe aortic valvular stenosis underwent a percutaneous TAVI procedure by direct puncture of the axillary artery without surgical cutdown. For safety reasons and as a target for the puncture, a wire was advanced via the ipsilateral brachial artery. Moreover, a balloon was placed into the subclavian artery via the femoral artery for temporary vessel blockade before percutaneous vessel closure. Vascular closure was performed using either the ProStar XL system (Abbott Vascular Devices, Redwood City, California) or 2 ProGlide systems (Abbott Vascular Devices).The true percutaneous approach was successfully completed in all patients (14 left and 8 right axillary artery cases). Overall mortality at 30 days was 8.3%. Acute vascular closure device success was achieved in 17 patients (71%). Vascular closure device success rate was 100% for the ProGlide device and 37% for the ProStar device, respectively. Seven patients (29%) with failing closure devices were treated by endovascular stent graft implantation without the need for surgical repair. For the last 12 treated patients, direct closure was achieved in 11 patients.Direct puncture of the axillary artery for TAVI is feasible and safe if a wire is placed into the subclavian artery via the ipsilateral brachial artery.

Valve-in-valve implantation for degenerated surgical bioprosthetic valves is becoming an increasingly accepted approach in selected high-risk patients. In the past, valve-in-valve implantations have been mainly performed in aortic position and only rarely in mitral position. We describe the case of an 81-year-old female patient with severe mitral regurgitation of a degenerated Carpentier-Edwards biological prosthesis treated by transfemoral and transseptal implantation of a SAPIEN-XT valve.

Transcatheter aortic valve implantation (TAVI) is a proven alternative to open heart surgery in elderly patients. Pulmonary hypertension (PH) is known as a significant risk factor in patients with severe aortic stenosis (AS) undergoing surgical aortic valve replacement. However, the prognostic impact of PH in high-risk patients undergoing TAVI is still unknown. The aim of this study was to gain more insight in the clinical outcome and mortality of patients with PH after TAVI. Between July 2009 and September 2012, a total of 439 patients were treated by TAVI in conjunction with a complete invasive right heart study at our institution. Patients were divided into two groups with regard to their pulmonary arterial mean pressure (PAMP) before TAVI (A: PAMP

Objectives: Most patients with chronic phase CML attain a complete cytogenetic response (CCR) to imatinib (IM) but BCR-ABL remains detectable by RT-PCR, indicating persistence of residual disease. One small study (Bhatia et al. Blood101(12):4701–7, 2003) suggested that the levels of minimal residual disease (MRD) in CCR patients may be highest in the CD34+ cells but it is not clear whether the cohort under study was truly representative of patients with stable CCR. To address this question, we compared the level of MRD in total white cells (TWC), CD34-positive (CD34+), CD34-negative (CD34−) and CFU-GM colonies in patients with a molecular response (MR, defined as a BCR-ABL / ABL ratio below 0.12% as suggested by Paschka et al. Blood104 (11): #1013, 2004) to IM. Patients and Methods: Twenty-two bone marrow samples were obtained from 13 CML patients with CCR [7 male/6 female, median age 57 (range 23–68) years]. At IM start all patients were in chronic phase (8 newly diagnosed, 5 refractory or intolerant to interferon alpha). The median time on IM at the date of the first analysis was 39 (range 10–50) month, the median duration of CCR and MR was 32 (range 4–49) and 20 (range 0–36) month, respectively. The frequency of CD34+ cells in unmanipulated BM as determined by FACS was compared to 33 patients with newly diagnosed CML and 9 healthy individuals. CD34+ cells were selected over immunomagnetic columns. At least 100 CD34+, CD34− and TWC were analyzed for BCR-ABL by FISH (Vysis LSI BCR-ABL ES probe, lab specific false positive rate of < 2%). CD34+ cells were plated in triplicate at 104 cells/ml and CFU-GM were counted on day 14. Quantitative PCR (qPCR) was performed on CD34+, CD34-, TWC and pools of 10 CFU-GM colonies. PCR-negative samples with less than 1000 copies of the ABL gene / μl cDNA were excluded. Results: The median frequencies of CD34+ cells in patients with MR, newly diagnosed patients and healthy controls were 0.30 (range 0.10–1.56)%, 3.81 (range 0.04–17.77)% and 0.88 (range 0.46 to 1.47)%, respectively (p Conclusion: In CML with MR to IM CD34+ cells are consistently BCR-ABL-negative. Comparable levels of BCR-ABL mRNA residual disease are present in total white cells, CD34+, CD34- and CFU-GM colonies, suggesting that residual disease is not limited to immature cells.