[Show abstract][Hide abstract] ABSTRACT: Objectives: To assess outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement but with less than high risk.Background: While there is abundant data for high risk patients there is insufficient data for reduced risk.Methods: Patients undergoing TAVI or SAVR between 2007 and 2012 in Karlsruhe were considered. They were assessed by cardiac computed tomography, transoesophageal echocardiogram, and logistic EuroSCORE I (ES) and groups compared using Propensity Score Matching.Results: The mean ES was 10.1±2.8 in the TAVI group (n=419) and 5.7±3.2 in the SAVR group (n=722; p<0.0001). Mean survival probability over three years was higher in patients undergoing surgery (p<0.0001). A total of 432 patients were considered for the matched-pairs analysis based on propensity scores (216 in each group). Major vascular complications (10.6% vs. 0.0%; p<0.0001), new pacemaker implantation (13.9% vs. 4.6%; p<0.001) and moderate aortic insufficiency (3.2% vs. 0.5%; p=0.03) were more frequent in patients undergoing TAVI. Major (20.8% vs. 4.2%; p<0.0001) and life-threatening (14.5% vs. 2.3%; p<0.0001) bleeding complications were more frequent in those undergoing surgery. Survival probability over three years in the propensity matched cohort was comparable between both groups (p=0.16).Conclusions: In this large, single center, real world dataset there was no difference in mortality between patients undergoing TAVI or SAVR during a 3 year follow-up but there was a TAVI related increase in major vascular complications, new pacemaker implantation and aortic insufficiency and a SAVR related increased bleeding risk. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Background:
Aortic rupture of the device landing zone is a rare complication of transcatheter aortic valve implantation (TAVI) and it is associated with significant mortality.
This study reports on the experience of a single-center in a case series of more than 1,000 implants. We explored patient and procedural characteristics aiming at identifying variables that increase the risk for aortic root rupture.
Among a total of 1,000 TAVI procedures, six patients (0.6 %) had a rupture of the device landing zone. Five of these patients received the balloon-expandable Edwards SAPIEN valve (5/813; 0.62 %) of which four had a supraannular and one a subannular rupture. One patient received the self-expanding Medtronic CoreValve (1/199; 0.5 %; p = n.s. vs. SAPIEN) and had an annular rupture. Factors that were associated with aortic rupture were: (1) the relative size of the valve compared with the aortic annulus and its geometric form; (2) the need for post-dilation of the new valve because of paravalvular leakage; and (3) the location and severity of calcification. We determined, to avoid aortic rupture, caution may be necessary in the presence of the following conditions: (1) flat sinuses of Valsalva and severe calcifications of either the body or the free edge of the aortic cusps (supraannular rupture); (2) an ellipsoid annulus and bulky calcifications on either the base of the cusps or the rim of the annulus (annular rupture); and (3) a narrow left-ventricular outflow tract (LVOT) and bulky calcification of the LVOT (subannular rupture). After considering these precautions, we observed no case of aortic root rupture in the following 600 cases.
The data indicate that to reduce the frequency of aortic rupture, a careful pre-procedural planning appears essential to avoid this serious and potentially deleterious complication.
Clinical Research in Cardiology 06/2014; 103(11). DOI:10.1007/s00392-014-0729-8 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
In the REPAIR-AMI trial, intracoronary infusion of bone marrow-derived cells (BMCs) was associated with a significantly greater recovery of contractile function in patients with acute myocardial infarction (AMI) at 4-month follow-up than placebo infusion. The current analysis investigates clinical outcome and predictors of event-free survival at 5 years.
Methods and results:
In the multicentre, placebo-controlled, double-blind REPAIR-AMI trial, 204 patients received intracoronary infusion of BMCs (n = 101) or placebo (n = 103) into the infarct vessel 3-7 days following successful percutaneous coronary intervention. Fifteen patients died in the placebo group compared with seven patients in the BMC group (P = 0.08). Nine placebo-treated patients and five BMC-treated patients required rehospitalization for chronic heart failure (P = 0.23). The combined endpoint cardiac/cardiovascular/unknown death or rehospitalisation for heart failure was more frequent in the placebo compared with the BMC group (18 vs. 10 events; P = 0.10). Univariate predictors of adverse outcomes were age, the CADILLAC risk score, aldosterone antagonist and diuretic treatment, changes in left ventricular ejection fraction, left ventricular end-systolic volume, and N-terminal pro-Brain Natriuretic Peptide (all P < 0.01) at 4 months in the entire cohort and in the placebo group. In contrast, in the BMC group, only the basal (P = 0.02) and the stromal cell-derived factor-1-induced (P = 0.05) migratory capacity of the administered BMC were associated with improved clinical outcome.
In patients of the REPAIR-AMI trial, established clinical parameters are associated with adverse outcome at 5 years exclusively in the placebo group, whereas the migratory capacity of the administered BMC determines event-free survival in the BMC-treated patients. These data disclose a potency-effect relationship between cell therapy and long-term outcome in patients with AMI.
European Heart Journal 05/2014; 35(19):1275-1283. DOI:10.1093/eurheartj/ehu062 · 15.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To present a detailed analysis of the cumulative radiation exposure and cancer risk of patients with ischemic heart diseases (IHD) from diagnostic and therapeutic imaging.
For 1219 IHD patients, personal and examination data were retrieved from the information systems of a university hospital. For each patient, cumulative organ doses and the corresponding effective dose (E¯) resulting from all imaging procedures performed within 3 months before and 12 months after the date of the diagnosis were calculated. The cumulative lifetime attributable risk (LAR¯) of the patients to be diseased by radiation-related cancer was estimated using sex-, age-, and organ-specific risk models.
Among the 3870 procedures performed in the IHD patients, the most frequent were radiographic examinations (52.4%) followed by coronary catheter angiographies and percutaneous cardiac interventions (41.3%), CT scans (3.9%), and perfusion SPECT (2.3%). 87% of patient exposure resulted from heart catheter procedures. E¯ and LAR¯ were significantly higher in males than females (average, 13.3 vs. 10.3mSv and 0.09 vs. 0.07%, respectively). Contrary to the effective dose, the cancer risk decreased markedly for both sexes with increasing age.
Although IHD patients were partially exposed to considerable amounts of radiation, estimated LAR¯s were small as compared to their baseline risk to develop cancer in the remaining life.
European journal of radiology 08/2013; 82(11). DOI:10.1016/j.ejrad.2013.07.015 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To quantitatively assess coronary atherosclerotic plaque composition in patients with acute non-ST elevation myocardial infarction (NSTEMI) and patients with stable coronary artery disease (CAD) by coronary computed tomography angiography (cCTA) correlated with virtual histology intravascular ultrasound (VH-IVUS).
Sixty patients (35 with NSTEMI) were included. Corresponding plaques were assessed by dual-source cCTA and VH-IVUS regarding volumes and percentages of fatty, fibrous, and calcified component; overall plaque burden; and maximal percent area stenosis. Possible differences between patient groups were investigated. Concordance between cCTA and VH-IVUS measurements was validated by Bland-Altman analysis.
Forty corresponding plaques (22 of patients with NSTEMI) were finally analyzed by cCTA and VH-IVUS. cCTA plaque analysis revealed no significant differences between plaques of patients with NSTEMI and stable CAD regarding absolute and relative amounts of any plaque component (fatty: 20 mm³/13% versus 17 mm³/14%; fibrous: 81 mm³/63% versus 80 mm³/53%; calcified: 16 mm³/14% versus 26 mm³/26%; all P > .05) or overall plaque burden (153 mm³ versus 165 mm³; P > .05), nor did VH-IVUS plaque analysis. VH-IVUS measured a higher area stenosis in patients with NSTEMI compared to patients with stable CAD (76% versus 68%, P = .01; in cCTA 69% versus 65%, P = .2). Volumes of fatty component were measured systematically lower in cCTA, whereas calcified and fibrous volumes were higher. No significant bias was observed comparing volumes of overall noncalcified component and overall plaque burden.
Plaques of patients with acute NSTEMI and of patients with stable CAD cannot be differentiated by quantification of plaque components. cCTA and VH-IVUS differ in plaque component analysis.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
The purpose of this study was to compare automated, motion-corrected, color-encoded (AMC) perfusion maps with qualitative visual analysis of adenosine stress cardiovascular magnetic resonance imaging for detection of flow-limiting stenoses.
Materials and methods:
Myocardial perfusion measurements applying the standard adenosine stress imaging protocol and a saturation-recovery temporal generalized autocalibrating partially parallel acquisition (t-GRAPPA) turbo fast low angle shot (Turbo FLASH) magnetic resonance imaging sequence were performed in 25 patients using a 3.0-T MAGNETOM Skyra (Siemens Healthcare Sector, Erlangen, Germany). Perfusion studies were analyzed using AMC perfusion maps and qualitative visual analysis. Angiographically detected coronary artery (CA) stenoses greater than 75% or 50% or more with a myocardial perfusion reserve index less than 1.5 were considered as hemodynamically relevant. Diagnostic performance and time requirement for both methods were compared. Interobserver and intraobserver reliability were also assessed.
A total of 29 CA stenoses were included in the analysis. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detection of ischemia on a per-patient basis were comparable using the AMC perfusion maps compared to visual analysis. On a per-CA territory basis, the attribution of an ischemia to the respective vessel was facilitated using the AMC perfusion maps. Interobserver and intraobserver reliability were better for the AMC perfusion maps (concordance correlation coefficient, 0.94 and 0.93, respectively) compared to visual analysis (concordance correlation coefficient, 0.73 and 0.79, respectively). In addition, in comparison to visual analysis, the AMC perfusion maps were able to significantly reduce analysis time from 7.7 (3.1) to 3.2 (1.9) minutes (P < 0.0001).
The AMC perfusion maps yielded a diagnostic performance on a per-patient and on a per-CA territory basis comparable with the visual analysis. Furthermore, this approach demonstrated higher interobserver and intraobserver reliability as well as a better time efficiency when compared to visual analysis.
[Show abstract][Hide abstract] ABSTRACT: Epicardial adipose tissue (EAT) is an active metabolic and endocrine organ. Previous studies focusing mainly on patients with preserved left ventricular function (LVF) could show a correlation between increased amounts of EAT and the extent and activity of coronary artery disease (CAD). However, to date, there are no data available about the relationship between EAT and the severity of CAD with respect to the whole spectrum of LVF impairment. Therefore, we evaluated this relationship in patients with CAD.
250 patients with CAD and 50 healthy controls underwent CMR examination to assess EAT. The severity of CAD was defined using the angiographic Gensini score (GSS).
The GSS ranged from 2-364. Linear regression analysis revealed a significant correlation between EAT and GSS (r = 0.177, p = 0.01). Patients with mild (GSS≤10) and moderate CAD (GSS>10-≤40) showed comparable EAT to healthy controls. However, in patients with severe CAD (GSS>40) EAT was significantly reduced (p<0.0001) compared to healthy controls. Interestingly, patients with the same GSS revealed different EAT depending on the left ventricular function (LVF). Patients with preserved LVF (LVF≥50%) showed more EAT mass compared to those with reduced LVF (LVF<50%) regardless of the GSS. In patients with preserved LVF and mild CAD, EAT was comparable to healthy controls (61.8±19.4 g vs. 62.9±14.4 g, p = 0.8). In patients with moderate CAD, EAT rose significantly to 83.1±24.9 g (p = 0.01) and started to decline to 66.4±23.6 g in patients with severe CAD (p = 0.03). Contrary, in CAD patients with reduced LVF, EAT was already significantly reduced in patients with mild CAD as compared to healthy controls (p = 0.001) and showed a stepwise decline with increasing CAD severity.
The relationship between EAT and the severity of CAD depends on LVF. These findings emphasize the multifactorial interaction between EAT and the severity of CAD.
PLoS ONE 11/2012; 7(11):e48330. DOI:10.1371/journal.pone.0048330 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To evaluate the impact of coronary CT angiography (coronary CTA) or "triple-rule-out" CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile.
Materials and methods:
100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE).
Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery. A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient.
Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.
European journal of radiology 06/2012; 82(1). DOI:10.1016/j.ejrad.2012.06.001 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This prospective study examines the impact of EuroSCORE and transfemoral (TF) or transapical (TA) delivery approach on mortality at 30 days and 1 year in patients with severe aortic stenosis implanted with either the Edwards SAPIEN Transcatheter Heart Valve (THV) or Medtronic CoreValve.
TAVI was successfully performed in 293 (97.7%) of 300 patients (TF: 174, TA: 126, mean EuroSCORE 24.0). The mortality at 30 days and after 1 year was 6.0% and 17.3%. Mortality depends significantly on the logistic EuroSCORE with a 30-day odds ratio (OR) of 1.92 (95% CI 1.41 to 2.62, P < 0.001) and after 1 year of 1.67 (95% CI 1.34 to 2.08, P < 0.001). Mortality in patients with a logistic EuroSCORE <15 (n = 113) or ≥15 (n = 187) at 30 days was 0.9% versus 9.1% and after 1 year 7.1% versus 23.5% demonstrating significantly less mortality (P < 0.001) in patients with lower logistic EuroSCOREs. In this specific setup of our center there was no significant difference (P = 0.553) in mortality regarding the technical approach for TA (4.0% and 15.9%) and for TF (7.5% and 18.4%). Severe cardiac complications occurred in 20 patients (6.7%) with a 30-day mortality of 45.0%.
The mortality in patients undergoing TAVI correlates significantly with the logistic EuroSCORE. Patients with a logistic EuroSCORE <15 can be implanted, with a low 30-day mortality and good long-term outcome over 1 year.
[Show abstract][Hide abstract] ABSTRACT: Newer techniques are required to identify atherosclerotic lesions that are prone to rupture. Electric impedance spectroscopy (EIS) is able to provide information about the cellular composition of biological tissue. The present study was performed to determine the influence of inflammatory processes in type Va (lipid core, thick fibrous cap) and Vc (abundant fibrous connective tissue while lipid is minimal or even absent) human atherosclerotic lesions on the electrical impedance of these lesions measured by EIS.
EIS was performed on 1 aortic and 3 femoral human arteries at 25 spots with visually heavy plaque burden. Severely calcified lesions were excluded from analysis. A highly flexible micro-electrode mounted onto a balloon catheter was placed on marked regions to measure impedance values at 100 kHz. After paraffin embedding, visible marked cross sections (n = 21) were processed. Assessment of lesion types was performed by Movats staining. Immunostaining for CD31 (marker of neovascularisation), CD36 (scavenger cells) and MMP-3 (matrix metalloproteinase-3) was performed. The amount of positive cells was assessed semi-quantitatively. 15 type Va lesions and 6 type Vc lesions were identified. Lesions containing abundant CD36-, CD31- and MMP-3-positive staining revealed significantly higher impedance values compared to lesions with marginal or without positive staining (CD36 + 455 ± 50 Ω vs. CD36- 346 ± 53 Ω, p = 0.001; CD31 + 436 ± 43 Ω vs. CD31- 340 ± 55 Ω, p = 0.001; MMP-3 + 400 ± 68 Ω vs. MMP-3- 323 ± 33 Ω, p = 0.03).
Atherosclerotic lesions with abundant neovascularisation (CD31), many scavenger receptor class B expressing cells (CD36) or high amount of MMP-3 immunoreactivity reveal significantly higher impedance values compared to lesions with marginal or no detection of immunoreactivity. Findings suggest that inflammatory processes in vulnerable plaques affect the impedance of atherosclerotic lesions and might therefore be detected by EIS.
PLoS ONE 04/2012; 7(4):e35405. DOI:10.1371/journal.pone.0035405 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this article is to assess aortic root and iliofemoral vessel anatomy and the frequency of clinically significant incidental findings on aortoiliac CT angiography (CTA) performed for planning of transcutaneous aortic valve implantation.
Aortoiliac CTA studies of 207 patients scheduled for transcutaneous aortic valve implantation were analyzed. Anatomic dimensions relevant to the interventional procedure, including diameter of the aortic annulus and sinus of Valsalva, distance between aortic annulus and coronary ostia, coronary leaflet length, left ventricular outflow tract diameter, and vessel diameter of iliac arteries, were analyzed. Clinically significant incidental findings were recorded.
The mean (± SD) maximum and minimum diameters of the aortic annulus were 29 ± 3.9 mm and 23.5 ± 4.1 mm, respectively. The mean distances between aortic annulus and the ostium of the left and right coronary artery were 13.5 ± 3.2 mm and 14.8 ± 3.9 mm, respectively. The mean maximum and minimum diameters of the left ventricular outflow tract were 27 ± 4 mm and 1.9 ± 4 mm, respectively. The mean diameter of the sinus of Valsalva was 33.4 ± 5.1 mm. The mean diameters of the right and left external iliac artery were 8 ± 1 and 8 ± 2 mm, respectively. Almost half the patients (101/207) had clinically significant incidental findings, including noncalcified pulmonary nodules larger than 8 mm (n = 7), pulmonary embolism (n = 3), or aortic aneurysm (n = 12).
Aortoiliac CTA provides relevant information on aortic root and iliofemoral vessel anatomy for preinterventional planning. CTA reveals clinically significant incidental findings in a high number of patients considered for transcutaneous aortic valve implantation, which may have a significant impact on patient selection.
American Journal of Roentgenology 04/2012; 198(4):939-45. DOI:10.2214/AJR.11.7231 · 2.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
To investigate the correlation of CT angiography (CTA) pulmonary artery obstruction scores with right ventricular dysfunction (RVD) and adverse clinical outcomes in patients with acute pulmonary embolism (PE).
METHOD AND MATERIALS
With IRB approval, 50 consecutive patients (mean age: 66±12.9 years) with acute PE were prospectively enrolled. CTA obstruction scores (Qanadli, Mastora, Mastora central) were jointly assessed by two radiologists. All patients underwent echocardiography for the assessment of RVD. CTA obstruction scores were correlated with RVD and adverse clinical outcomes (defined as death, need for intensive care treatment, or NYHA≥grade III).
Mean CTA obstruction scores were 26.4 ± 17.7, 12.6 ± 9.9 and 7.5 ± 9 for Mastora, Qanadli and Mastora central, respectively. Based on echocardiography, severe and moderate RVD were found in 5 and 10 of the 50 patients, respectively. All three CTA obstruction scores were significantly higher in patients with RVD than those without RVD (p<0.05). Eighteen patients (36%) had an adverse clinical outcome, however, CTA obstruction scores did not differ significantly between patients with or without adverse clinical outcome. 50% of patients (9/18) with adverse clinical outcome had RVD (n=9, p= 0.0281).
All three CTA obstruction scores were able to differentiate between patients with RVD and those without RVD. However, in this preliminary cohort, none of the obstruction scores were predictive of clinical outcome.
CTA obstruction scores enable the identification of patients with RVD but seem less predictive of patient outcome.
Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 11/2011
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
ECG gated CT angiography (CTA) has been proposed for assessing the dimensions of the aortic annulus (AA) and left ventricular outflow tract (LVOT) for sizing of valve prostheses at transfemoral aortic valve implantation (TAVI). The purpose of this study was to evaluate, whether the reconstruction phase (systolic or diastolic) at CTA affects the valve sizing.
METHOD AND MATERIALS
42 patients (mean age 80±8 years, 27 female) scheduled for aortic valve implantation were examined by CTA. The dimensions of the AA and LVOT were measured in systolic and diastolic reconstructions (30% and 70%) using multiplanar reformats orientated along the valvular plane and perpendicular to the LVOT axis. Differences of the maximum and minimum diameter of the AA and LVOT on systolic and diastolic phases were compared. Furthermore, in patients who were already operated (n=28) measurements were compared to the size of the valve used at TAVI.
Dimensions of the AA and LVOT did not significantly differ between systolic and diastolic phases (e.g. maximum diameter: AA 26.8 +/-3 mm vs. 26.7 +/-3 mm and LVOT 27.2+/-3 mm vs. 27.6+/3 mm; p>0.05). Although not significant, there was a trend towards better prediction of the final valve size using the maximum diameter of the AA and LVOT.
The reconstruction phase of CTA does not seem to affect the dimensions of the AA and LVOT. The maximum diameter seems to predict the valve size of TAVI more precisely.
ECG gated CTA allows reliable sizing of valve prostheses at TAVI independent of the reconstruction phase.
Radiological Society of North America 2011 Scientific Assembly and Annual Meeting; 11/2011