Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis.

BACKGROUND: Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. METHODS: Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. RESULTS: ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. CONCLUSION: Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.

Recurrent Cardiac Constriction after Implantation of an Expanded Polytetrafluoroethylene Surgical Membrane.

One of the challenges compounding the complexity of reoperative cardiac surgery is the surgical adhesion, which can be responsible for adverse intraoperative events. Implantation of a substitute neo-pericardium has become a frequently used solution, with currently rising numbers of reoperations. We report the case of a 38-year-old man who developed recurrent delayed cardiac constriction following the implantation of an expanded polytetrafluoroethylene neo-pericardium. Careful preoperative planning is recommended to plan the optimal method of pericardioplasty, taking into account the pros and cons of each available material.

Prognostic impact of invasive exercise haemodynamics in patients with severe mitral regurgitation.

OBJECTIVES: Abnormal invasive exercise haemodynamics in asymptomatic patients with severe mitral regurgitation were associated with higher regurgitation burden. We analysed the association between parameters of invasive exercise testing with mortality and valve surgery compared to guideline defined non-invasive criteria. METHODS: This single centre, retrospective cohort study assesses the association of invasive exercise haemodynamics and mortality with and without surgery in patients with severe mitral regurgitation and normal ejection fraction (≥55%) as primary outcome. The secondary outcome was the need for mitral valve surgery in 113 asymptomatic patients primarily managed conservatively. RESULTS: We identified 314 patients [age 59 years (standard deviation 13), 27% female] with available exercise haemodynamics with a median follow-up of 8.2 (interquartile range 5.2-11.2) years. Five-year survival rate was 93.0%. Pulmonary capillary wedge pressure at maximum exercise >30 mmHg was the only parameter independently associated with mortality after adjustment for age and guideline criteria [hazard ratio (HR) 2.7 (1.3-5.6), P = 0.007]. In the 113 patients primarily managed conservatively, maximum pulmonary capillary wedge pressure was independently associated with mitral valve surgery during follow-up in multivariable analysis (HR 2.10 (1.32-3.34), P = 0.002; after adjustment for workload and weight: HR 1.31 (1.14-1.52), P < 0.001], whereas systolic pulmonary artery pressure and current guideline criteria were not. Adding maximum pulmonary capillary wedge pressure >25 mmHg improved the predictive power of current guideline criteria for surgery (area under the curve 0.61-0.68, P = 0.02). CONCLUSIONS: Invasive exercise haemodynamics predict mortality and improve prognostic information about surgery during follow-up derived from current guideline criteria in asymptomatic patients with severe mitral regurgitation.

Amplified P-wave duration predicts new-onset atrial fibrillation in patients with heart failure with preserved ejection fraction.

BACKGROUND: Atrial fibrillation (AF) increases morbidity and mortality in heart failure with preserved ejection fraction (HFpEF), yet identification of HFpEF-patients at risk for new-onset AF is challenging. Amplified P-wave duration (APWD) non-invasively detects arrhythmogenic atrial substrate with high accuracy. We hypothesized that APWD may help in the prediction of new-onset AF in HFpEF. METHODS: Patients with suspected HFpEF (n = 99, left ventricular ejection fraction > 50%, no evidence of valvulopathy, coronary artery disease, or non-cardiac dyspnea) underwent exercise testing with concomitant right-heart catheterization. Normal resting pulmonary capillary wedge pressure (PCWP; < 12 mmHg) with an increase during exercise > 25.5 mmHg/W/kg defined early HFpEF. Advanced HFpEF was diagnosed with PCWP > 12 mmHg at rest. Arrhythmogenic atrial substrate (defined as APWD > 150 ms) was investigated on digitized standard 12-lead ECGs and patients were followed for new-onset AF at 6-month intervals. RESULTS: Forty-seven patients had normal exercise haemodynamics and served as controls. Early and advanced HFpEF was diagnosed in 29 and 23 patients, respectively. Eighty-seven per cent of patients with advanced HFpEF had evidence of arrhythmogenic atrial substrate, (APWD 175 ± 29 ms vs. 132 ± 14 ms in controls, p < 0.0001), which was associated with a tenfold increased risk for new-onset AF during 4.6 years of follow-up (hazard ratio [HR] 9.684, 95% CI 2.61-35.89, p < 0.0001). Early HFpEF was neither related to APWD (p = 0.395), nor to a higher risk for AF (HR 3.44, 95% CI 0.57-20.72, p = 0.178). Importantly, the presence of arrhythmogenic substrate was independent of left atrial indexed volume. CONCLUSION: The analysis of amplified P-wave duration (APWD) allows for the prediction of new-onset AF in patients with advanced HFpEF.

Does the heart transplant have a future?

Heart failure has remained the leading cause of death globally for the last 15 years-and its prevalence will continue to rise. Fifty years ago, heart failure management was enriched by the possibility of a heart transplant. Despite impressive improvements in medical treatment for heart failure, a heart transplant remains the most effective long-lasting treatment for advanced heart failure in terms of mortality and quality of life. However, donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and to more demanding operations and postoperative management. With improving pathophysiological understanding in the last decades, today's scientific interest still focuses on basic knowledge. How to retrieve and conserve organs to minimize ischaemic injury; how best to allocate them, considering the likelihood of success (developing a heart-allocation scoring system similar to that for lung allocation); how to match donor/recipient characteristics (ABO blood-group antigen compatibility versus incompatibility); and how to avoid graft failure, rejection and secondary morbidities such as malignomas and cardiac allograft vasculopathy after the heart transplant-all these factors remain fundamental challenges in today's transplant medicine. The use of ex vivo perfusion (e.g. via the Organ Care System®, TransMedics, Andover, MA, USA) may play an important role in this change. Remarkably, there are huge regional divergences in current transplant practices: Whereas the number of transplants continues to rise in most Eurotransplant countries and other major transplant networks, there are some countries in which transplant numbers are static or even dropping (as in Germany). This difference results in wide variations across different countries as to how advanced heart failure is treated using mechanical circulatory-assist devices.

Body image after heart transplantation compared to mechanical aortic valve insertion.

OBJECTIVE: Heart transplantation (HT) obviously affects body image and integrity. However, there are very few empirical data post-transplant. METHODS: In a cross-sectional study, 57 HT patients were compared with 47 subjects with mechanical aortic valve replacement (AVR) using the Dresden-Body-Image questionnaire (DKB) and specific questions regarding integration of the organ/device. In addition, affective symptoms and quality of life (QoL) were assessed (12-Item Short-Form Health Survey and Hospital Anxiety and Depression Scale, HADS). RESULTS: DKB-35 scores did not differ. HT patients scored higher than AVR on specific questions regarding integration of the organ/device. AVR patients showed more affective disturbance and lower mental QoL than HT subjects. Affective scores correlated negatively with body image scores. Seventeen percent of all patients showed psychological distress (HADS scores >8). CONCLUSIONS: HT patients integrated the new organ well - and even better than AVR subjects did with the device. In general, our data corroborate a good adaptation process, in particular in HT patients. Similar to other reported data, a subgroup of 15-20% of patients shows stronger mental distress, including body image problems. These must be identified and treated by professionals. Patients with AVR deserve more attention in the future.

Mental health status of patients with mechanical aortic valves, with ventricular assist devices and after heart transplantation.

OBJECTIVES: Mental health is a complex construct, in which emotional aspects and quality of life are central. It has been assessed in patients after heart transplantation (HTX) and occasionally in those with ventricular assist devices (VADs). However, there are no studies that compare patients with primary HTX with those with HTX ending VAD support. Evidence for patients with mechanical aortic valve replacement is also limited. We compared mental outcome for these four groups for the first time. We also focused on the question of an artificial device, i.e. VAD or mechanical aortic valve, as distinct from a biological graft, i.e. HTX. METHODS: Two questionnaires were applied: The Hospital Anxiety and Depression Scale, the German version consists of two subscales for anxiety and for depression, and the 12-item Short Form Health Survey, the German version contains two subscales for physical and for mental performance measuring quality of life. We included 46 patients with mechanical aortic valve replacement, 55 after HTX and 22 on support by a long-term VAD. The HTX group consisted of 38 patients with primary HTX and 17 recipients who were on VAD support before transplantation. The index operation was at least 6 months ago. RESULTS: HTX patients suffered less from anxiety and depression than patients with mechanical aortic valve replacement or those on VAD. HTX patients had higher scores on the physical scale but not on the mental component scale of the 12-item Short Form Health Survey compared with VAD patients. Conversely, patients with mechanical aortic valve replacement did worse with regard to mental but not physical performance compared with HTX patients. VAD and mechanical aortic valve replacement patients differed only with regard to physical condition, but not with regard to anxiety, depression and mental status. HTX patients with and without VAD support before transplantation achieved similar values on all scales. Mental scales did not correlate with age or time after surgery. CONCLUSIONS: HTX patients had the best outcome compared with the other groups with respect to mental health. Mechanical aortic valve replacement patients did not differ from VAD patients with respect to anxiety, depression and mental quality of life scores. Mechanical aortic valve replacement patients might be more in need of psychological support than expected. Further, VAD patients who undergo HTX reach similar mental and physical results when compared with patients with primary HTX, i.e. they seem to cope well in the long run.

The porcine valve type predicts obstructive thrombosis beyond the first three postoperative months in bioprostheses in the aortic position.

BACKGROUND: Obstructive thrombosis of bioprosthetic valves is considered rare but may have dramatic consequences for the individual patient including repeat valve replacement, thrombolysis, or long-term anticoagulation. Whether the risk of obstructive thrombosis is dependent on the type of bioprosthesis (porcine versus bovine pericardial) is uncertain. METHODS AND RESULTS: Between 2007 and 2012 a total of 1751 patients received a single stented bioprosthesis in the aortic valve position, 749 (43%) were porcine and 1002 (57%) bovine. During a mean follow-up of 3.4±1.9years, obstructive thrombosis (identified by an increase in mean pressure gradient≥20mm Hg or a decrease in velocity ratio≥0.05 and confirmed by either ECG-gated computer tomography, a return to baseline of stenosis parameters under treatment with a vitamin K antagonist, or histology in case of reoperation) was diagnosed in 17 patients with a porcine (2.3%) and none with a bovine valve (p<0.001). The cumulative probability of developing an obstructive thrombosis was significantly higher in patients with a porcine valve (p<0.001 log-rank test). Adjusting for differences in baseline variables and stratification by the estimated propensity score showed that strata with a high probability of receiving a bovine valve had the highest number of obstructive thrombosis in porcine valves. These findings were further confirmed in a Poisson model and a competing risk model including all-cause mortality. Treatment of obstructive thrombosis with a vitamin K antagonist was safe and effective in 15/17 patients. CONCLUSION: The porcine valve type is an independent predictor of obstructive thrombosis in bioprostheses in the aortic position.

Valve thrombosis 7 months after transcatheter aortic valve implantation.

A 77-year old man underwent transcatheter aortic valve implantation for severe aortic stenosis with a 29-mm Edwards-Sapien XT aortic valve bioprosthesis. Periprocedural transesophageal echocardiography and computed tomography showed good positioning and expansion of the prosthesis with only minor transvalvular insufficiency. On a routine checkup 7 months later, echocardiography and computed tomography showed a high transvalvular gradient suggestive of valve thrombosis, which could not be treated with warfarin. Because of rapid deterioration of the patient's clinical condition, an urgent surgical valve replacement was performed 4 weeks after initial notice of the valve thrombosis. The patient's postoperative stay was uneventful.

Pulmonary capillary wedge pressure during exercise and long-term mortality in patients with suspected heart failure with preserved ejection fraction.

AIMS: In patients with suspected heart failure with preserved ejection fraction (HFpEF), invasive exercise testing may be considered when measurements at rest are inconclusive. However, the prognostic impact of invasive exercise testing is uncertain, so far. METHODS AND RESULTS: We retrospectively analysed mortality in 355 patients [mean age 61.2 ± 11.3 years, 235 (66.2%) women] with unexplained dyspnoea and suspected HFpEF. During an invasive haemodynamic stress test pulmonary capillary wedge pressure (PCWP) at rest and the PCWP response to exercise, expressed as the ratio of PCWP at peak exercise to workload normalized to body weight [PCWL (mmHg/W/kg)], were recorded. Both PCWP at rest and PCWL were significant and independent predictors of long-term mortality. Adding PCWL to PCWP at rest improved reclassification of patients into survivors or non-survivors with a net reclassification improvement (NRI) of 0.56 (95% CI: 0.29-0.83; P < 0.001). Ten-year mortality was 6.6% in subjects with low PCWP at rest (≤ 12 mmHg) and low PCWL (≤ 25.5 mmHg/W/kg); 28.2% in patients with low PCWP and high PCWL and 35.2% in those with high PCWP and high PCWL. Compared with patients with low PCWP and low PCWL, the adjusted hazard ratio for mortality was 2.37 (95% CI: 1.09-5.17; P = 0.029) for the low-PCWP/high-PCWL group and 4.75 (95% CI: 1.90-11.84; P < 0.001) for patients with high PCWP/high PCWL. CONCLUSION: In patients with suspected HFpEF, invasive exercise testing substantially improves prediction of long-term mortality. An excessive rise of PCWP during exercise despite normal PCWP at rest is associated with increased mortality and may be considered as early HFpEF.

4D-cine CT imaging of a bicuspid pulmonary valve.

A 71-year-old woman underwent diagnostic workup for progressive shortness of breath. Transthoracic echocardiography showed a dilated main pulmonary artery (MPA) and an anomalous configuration of the pulmonary valve. CT revealed a bicuspid pulmonary valve (BPV) and confirmed MPA dilation. Further congenital abnormalities were excluded. An isolated finding of BPV is rather rare. To our knowledge we present the first 4-dimensional CT images of a BPV. As in this case, 4-dimensional cine cardiac CT may be helpful to reveal the underlying cause of MPA dilation.

Does listing for heart transplant for longer than 30 days before ventricular assist device implantation influence utilization of psychotherapeutic support and outcome?

OBJECTIVES: Previous studies indicate that patients with mechanical ventricular assist devices (VADs) experience high psychosocial and emotional distress. Listing for transplant may trigger psychosocial adjustment to the transplantation as an upcoming critical life-event. We hypothesized that patients could profit from this adaptation when implantation of a VAD becomes necessary. METHODS: We arbitrarily chose a cut-off at 30 days after being put on the heart transplantation (HTX) waiting list. Eighteen patients were listed for HTX for >30 days (referred to as 'listed') and 26 for shorter periods or not at all ('non-listed'). Survival, the occurrence of mental disorders, the number of contacts of the patient with the psychologist and times spent on psychotherapeutic support for both patient groups and for their families were analysed. RESULTS: Survival after VAD implantation (observation time) and mental disorders were comparable for listed and non-listed patients. Mental disorders were developed in 80% of all patients irrespective of the listing group. The utilization of supportive psychotherapy did not differ between the listed and the non-listed group with regard to the number of contacts and to the time needed for individual therapy. Moreover, the number of families who requested support did not differ between the groups nor did the time spent on family therapy. However, the number of contacts and the time for individual psychotherapeutic support correlated with the observation time, whereas the time spent on family therapy did not. In contrast, family therapy correlated inversely with age. In addition, we compared bridge-to-transplantation patients with destination therapy patients. There were no differences in the occurrence of mental disorders, the number of contacts or in the time expenses for individual and for family therapy, neither for all patients nor after stratification for listing. CONCLUSIONS: Our data indicate that listing for HTX for >30 days before VAD implantation does not reduce the utilization of psychotherapeutic support by VAD patients. We assume that structured emotional and psychosocial support by the interdisciplinary VAD team, including professional supportive psychotherapy, is indispensable for successful coping of VAD patients and their families.

Novel correlations between the genotype and the phenotype of hypertrophic and dilated cardiomyopathy: results from the German Competence Network Heart Failure.

AIMS: Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) can both be due to mutations in the genes encoding ß-myosin heavy chain (MYH7) or cardiac myosin-binding protein C (MYBPC3). The aim of the present study was to determine the prevalence and spectrum of mutations in both genes in German HCM and DCM patients and to establish novel genotype-to-phenotype correlations. METHODS AND RESULTS: Coding exons and intron flanks of the two genes MYH7 and MYBPC3 of 236 patients with HCM and 652 patients with DCM were sequenced by conventional and array-based means. Clinical records were established following standard protocols. Mutations were detected in 41 and 11% of the patients with HCM and DCM, respectively. Differences were observed in the frequency of splice site and frame-shift mutations in the gene MYBPC3, which occurred more frequently (P< 0.02, P< 0.001, respectively) in HCM than in DCM, suggesting that cardiac myosin-binding protein C haploinsufficiency predisposes to hypertrophy rather than to dilation. Additional novel genotype-to-phenotype correlations were found in HCM, among these a link between MYBPC3 mutations and a particularly large thickness of the interventricular septum (P= 0.04 vs. carriers of a mutation in MYH7). Interestingly, this correlation and a link between MYH7 mutations and a higher degree of mitral valve regurgitation held true for both HCM and DCM, indicating that the gene affected by a mutation may determine the magnitude of structural and functional alterations in both HCM and DCM. CONCLUSION: A large clinical-genetic study has unravelled novel genotype-to-phenotype correlations in HCM and DCM which warrant future investigation of both the underlying mechanisms and the prognostic use.

Pulmonary hypertension due to left heart disease: updated Recommendations of the Cologne Consensus Conference 2011.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension (PH) have been adopted for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more frequent forms of PH including PH owing to left heart disease. The guidelines point out that the drugs currently used to treat patients with PAH (prostanoids, endothelin receptor antagonists and phosphodiesterase type 5 inhibitors) have not been sufficiently investigated in other forms of PH. However, despite the lack of respective efficacy data an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH due to left heart disease. This commentary describes in detail the results and recommendations of the working group which were last updated in October 2011.

Angiographic assessment of cardiac allograft vasculopathy: results of a Consensus Conference of the Task Force for Thoracic Organ Transplantation of the German Cardiac Society.

Angiograms of cardiac transplant (HTx) recipients were to be evaluated in a ring experiment and a joint consensus on criteria of angiographic evaluation of coronary arteries of HTx patients was to be reached. Twenty-four coronary angiograms from 11 hospitals were circulated. One hundred eighty-eight blinded evaluations were returned. A joint evaluation by six experienced cardiologists was used as reference standard and a consensus evaluation form was developed. Significant lesions (stenosis 75%, 50% in the left main coronary artery) were diagnosed in 10/23 abnormal coronary angiograms (41.7%). Interventional revascularization was recommended in 8/10 (80%). In 21 coronary angiograms distal pruning was found and in 11/21 (52.4%) cases with distal pruning occlusion of at least one peripheral vessel was detected. The best kappa value (0.7) was found for the presence of at least one clinically significant stenosis. Agreement on the site and grade of local stenosis was much less. Some agreement on remodeling was found in assessing diffuse narrowing in the LCA (kappa=0.371, P<0.001). The kappa value for peripheral obliteration was 0.331 (P=0.001). Angiographic evaluation of cardiac allograft vasculopathy, particularly of diffuse and peripheral disease and remodeling, needs standardization. This should be performed in a downward compatible improvement process.

Reducing the ischemic time of donor hearts will decrease morbidity and costs of cardiac transplantations.

With liberalization of donor eligibility criteria, donor hearts are being harvested from remote locations, increasing ischemic times. The aim of this study was to examine the effect of total ischemic time (TIT) on length of stay in the intensive care unit (LOS in ICU) and its economic consequences. The study population included recipients without prior mechanical support undergoing heart transplantation between 1998 and 2008 at a single institution. The mean age of the 72 recipients (56 men, 16 women) was 50.6 years (range 15-68 years) and the mean donor age was 41.5 years (range 11-61 years). The median TIT was 181.2 min (range 107-243) and median LOS in ICU was 11.5 days (range 3-107 days). There was a statistically significant linear relationship between TIT and LOS in ICU r(72)=0.317, P=0.004. Each 5 min and 38 s of TIT equated to one more day in ICU. An ischemic time >180 min was associated with higher LOS in ICU, renal failure, and a more frequent use of nitric oxide in our cohort. For longer distance harvesting, the reduction of TIT by the fastest possible transport (learjet, helicopter) would have economic advantages with regards to the high cost of treatment in ICU.