Midterm outcomes of LAA occlusion with the AMPLATZER Cardiac Plug and AMPLATZER Amulet devices in a high-risk cohort.

LAA occlusion has become a favourable option in patients with atrial fibrillation not eligible for oral anticoagulation therapy. Proof of effectiveness of LAA closure devices in a midterm follow-up period. This retrospective single-center cohort study analysed outcome in patients treated with AMPLATZER Cardiac Plug or AMPLATZER Amulet device. A standardized follow-up by phone call focusing on data of death, stroke and bleeding events was performed. Routine antiplatelet strategy was DAPT for 3 months post procedural. 212 patients (mean age 77 ± 6 years) were included. Follow up was performed in 197 (93%) patients. Patients were at high risk for thromboembolic or bleeding events (prior stroke/TIA 29%; prior bleeding 54%. Overall, there was a mean follow-up period of 1244.2 days (± 756.7) and a total of 674 patient years. We observed 25 events later than day 8 post procedure. We were able to demonstrate a high effectiveness of the AMPLATZER Cardiac Plug/AMPLATZER Amulet devices regarding the prevention of stroke and bleedings in a high-risk real-world cohort during a midterm follow-up period. Overall, we observed remarkably lower rates of stroke and bleedings as predicted with CHA2DS2-VASc and HASBLED scores.

Acute and Long-Term Hemodynamic Effects of MitraClip Implantation on a Preexisting Secondary Right Heart Failure.

Positive results of MitraClip in terms of improvement in clinical and left ventricular parameters have been described in detail. However, long-term effects on secondary pulmonary hypertension were not investigated in a larger patient cohort to date. 70 patients with severe mitral regurgitation, additional pulmonary hypertension, and right heart failure as a result of left heart disease were treated in the heart centers Hamburg and Göttingen. Immediately after successful MitraClip implantation, a reduction of the RVOT diameter from 3.52 cm to 3.44 cm was observed reaching a statistically significant value of 3.39 cm after 12 months. In contrast, there was a significant reduction in the velocity of the tricuspid regurgitation (TR) from 4.17 m/s to 3.11 m/s, the gradient of the TR from 48.5 mmHg to 39.3 mmHg, and the systolic pulmonary artery pressure (PAPsyst) from 58.6 mmHg to 50.0 mmHg. This decline continued in the following months (Vmax TR 3.09 m/s, peak TR 38.6 mmHg, and PAPsyst 47.4 mmHg). The tricuspid annular plane systolic excursion (TAPSE) increased from 16.5 mm to 18.9 mm after 12 months. MitraClip implantation improves pulmonary artery pressure, tricuspid regurgitation, and TAPSE after 12 months. At the same time, there is a decrease in the RVOT diameter without significant changes in other right ventricular and right atrial dimensions.

MitraClip® and Amplatzer® cardiac plug implantation in a single procedure: A reasonable approach?

BACKGROUND: Percutaneous mitral valve repair using MitraClip® (MC) is a well-established method for a subset of patients with severe mitral regurgitation (MR) and high risk for surgical intervention. Amplatzer® Cardiac Plug (ACP) occludes left atrial appendage and allows the discontinuation of oral anticoagulation and prevention of thromboembolic stroke. Due to the need for femoral and transseptal access in both procedures, a single approach could lead to minor risk of further complications and shorter cumulative intervention time. METHODS: We systematically analysed all four patients who underwent a combined procedure with MC and ACP in our heart-centre. All procedures were performed under fluoroscopic as well as echocardiographic guidance, and follow-up controls in a midterm period were carried out. RESULTS: In all patients (2 male/female; age 73-88years), MC (1-2 Clips) and ACP (size 18-28mm) were successfully implanted in one procedure (mean total time: 114±17min). At least moderate MR was achieved and two patients had no complications and therefore were discharged early. In a third patient, a dislocation of ACP occurred 2h after the implantation. The oldest patient developed a respiratory insufficiency due to cardiac decompensation and further complications. CONCLUSION: A combination of MC and ACP in a single procedure was feasible in this first case series of patients without a significant extension of procedure time. However, it might be important to select patients carefully. The location of optimal transseptal puncture may be challenging in regard to ACP placement, even in experienced hands and subsequent complications can occur.

[Catheter-based mitral valve repair by MitraClip implantation : Development, studies, and use in clinical practice]. / Kathetergestützte Mitralklappenreparatur mittels MitraClip : Entwicklung, Studienlage und Einsatz im Klinikalltag.

The percutaneous edge-to-edge mitral valve repair with MitraClip® is evolving as a potential alternative to conventional surgery in high-risk patients with significant mitral regurgitation (MR). The randomized controlled EVEREST II-trial which compared percutaneous repair versus surgery in operable patients with symptomatic severe MR demonstrated superior safety of MitraClip® implantation but better MR reduction after surgery at 12 months. However, large registries on MitraClip® therapy showed that real-world MitraClip® patients differ significantly from the EVEREST II-cohort: they are older, in more advanced stages of heart failure, present predominantly with secondary MR, and exhibit a higher burden of comorbidities. For these patients, registry data confirm a low incidence of peri-interventional complications and a significant improvement of heart failure symptoms and quality of life measures after MitraClip® implantation. The ongoing RESHAPE trial with randomization of MitraClip® implantation against optimal medical therapy investigates a possible survival benefit after MitraClip® in patients with secondary MR.

[Free-floating right heart thrombi in pulmonary embolism: therapeutic options and differential diagnosis]. / Flottierende rechtskardiale Transit-Thromben bei akuter Lungenembolie: Therapeutische Optionen und Differenzialdiagnosen

BACKGROUND: There is little published evidence on the treatment of mobile masses in the right heart. We report the clinical courses of three consecutive patients presenting with acute pulmonary embolism and mobile masses in the right heart. HISTORY AND ADMISSION FINDINGS: Three women, aged 75, 72 and 52 years, were hospitalized within three months because of dyspnea and suspected pulmonary embolism. INVESTIGATIONS: Transthoracic echocardiography revealed right ventricular dysfunction and highly mobile masses, which were considered as in-transit right heart thrombi in all cases. TREATMENT AND COURSE: All patients received immediate thrombolytic therapy (alteplase). No bleeding complications occurred. Thrombolysis was successful in the first two cases. However, the mass in the right ventricle did not disappear after thrombolysis in the third case and was removed surgically later on. The definite histological diagnosis was a myxoma of the right ventricle. CONCLUSION: According to literature, in-transit right heart thrombi are a potentially life-threatening complication of pulmonary embolism even in stable patients. Immediate thrombolysis is a valid therapeutic option and was successfully performed in 2 of our 3 patients. However, as case 3 suggests, differential diagnoses concerning mobile masses in the right heart, i. e. cardiac myxoma, should be taken into account and excluded by thoracic computed tomography .

[Diabetes increases short- and long-term mortality after transcatheter aortic valve implantation (TAVI)]. / Diabetes mellitus erhöht die eingriffsbedingte und die langfristige Mortalität nach kathetergestützter Aortenklappenimplantation.

BACKGROUND AND AIM: Long-term mortality after transcatheter aortic valve implantation (TAVI) in elderly patients with abundant comorbidities is considerable. We aimed to determine the impact of diabetes on short- and long-term mortality after TAVI. METHODS: Our study includes 300 consecutive patients (mean age, 82 ± 5 years) who underwent TAVI (158 transapical, 142 transfemoral procedures). All patients were followed by regular telephone contacts. 36% suffered from diabetes. RESULTS: Diabetes could be identified as significant predictor of short- and long-term mortality after TAVI. In diabetic patients, 30-day-mortality was 2,5 fold elevated (18.3% vs. 7.3%, p = 0.004). Furthermore, they were at significantly higher risk of peri-interventional stroke (p = 0.04), stage 3 acute kidney injury (p = 0.003), and prolonged ventilation (p = 0.01). Even after successful TAVI and discharge from hospital, long-term mortality was significantly elevated in diabetic patients (56% vs. 30%, p < 0.0001). Of note, 25% of diabetic vs. only 8% of non-diabetic patients died from cardiac causes during follow-up, suggesting that TAVI is not able to reduce cardiac-related mortality risk in diabetic patients to the same extent as in non-diabetics. CONCLUSION: Diabetes represents a powerful predictor of adverse early and late outcome after TAVI. These findings should be incorporated into the assessment of the risk-to-benefit ratio of TAVI in diabetic patients.

Natural Suppression of Rhizoctonia Bare Patch in a Long-Term No-Till Cropping Systems Experiment.

The soilborne fungus Rhizoctonia solani AG-8 is a major concern for farmers who practice no-till in the inland Pacific Northwest of the United States. Bare patches caused by Rhizoctonia spp. first appeared in 1999 during year 3 of a 15-year no-till cropping systems experiment near Ritzville, WA (269 mm of annual precipitation). The extent and pattern of patches were mapped each year from 1999 to 2012 at the 8-ha study site with a backpack-mounted global positioning system equipped with mapping software. Bare patches appeared in winter and spring wheat (SW; Triticum aestivum), spring barley (SB; Hordeum vulgare), yellow mustard (Brassica hirta), and safflower (Carthamus tinctorius). At its peak in years 5 to 7, bare patches occupied as much as 18% of total plot area in continuous annual monoculture SW. The area of bare patches began to decline in year 8 and reached near zero levels by year 11. No measurable patches were present in years 12 to 15. Patch area was significantly greater in continuous SW compared with SW grown in a 2-year rotation with SB. Additionally, the 15-year average grain yield for SW in rotation with SB was significantly greater than for continuous SW. Russian thistle (Salsola tragus), a troublesome broadleaf weed with a fast-growing tap root, was the only plant that grew within patches. This article reports the first direct evidence of natural suppression of Rhizoctonia bare patch with long-term no-till in North America. This suppression also developed in a rotation that contained broadleaf crops (yellow mustard and safflower) in all but 5 years of the study, and the suppression was maintained when safflower was added back to the rotation.

Percutaneous interventional mitral regurgitation treatment using the Mitra-Clip system.

The interventional treatment of mitral valve regurgitation by the MitraClip procedure has grown rapidly in Germany and Europe during the past years. The MitraClip procedure has the potential to treat high-risk patients with secondary mitral valve regurgitation and poor left ventricular function. Furthermore, patients with primary mitral valve regurgitation may be treated successfully by the MitraClip procedure in case of high surgical risk or in very old patients. At the same time it has been emphasised that the MitraClip interventional treatment is still at an early stage of clinical development. The largest clinical experience with the MitraClip procedure so far is probably present in some German cardiovascular centers, which here summarise their recommendations on the current indications and procedural steps of the MitraClip treatment. These recommendations of the AGIK and ALKK may present a basis for future development.

[TRAMI (Transcatheter Mitral Valve Interventions) register. The German mitral register]. / TRAMI (Transcatheter Mitral Valve Interventions)-Register. Das Deutsche mitralklappen-register

The transcatheter mitral valve interventions (TRAMI) registry was established in 2010 in order to assess the safety and efficacy of percutaneous mitral valve therapy in Germany and to document baseline characteristics and decision-making in different subgroups of patients. The TRAMI registry is available to all German sites performing percutaneous mitral valve therapy. Follow-up is scheduled at 30 days, 1, 3, and 5 years. In addition, patients can be enrolled retrospectively without predefined times of follow-up. The vast majority of patients enrolled in TRAMI underwent MitraClip® therapy. As of March 2013, a total of 1,064 patients treated with MitraClip® have been enrolled at 21 different German sites. Preliminary results show that patients treated with MitraClip® in Germany were mainly elderly patients with significant comorbidities and high or inacceptable risk of surgery. The majority of patients had secondary mitral regurgitation and a large proportion of patients had reduced left ventricular ejection fraction (LV-EF). Nevertheless, MitraClip® was found to be safe and established risk factors for conventional cardiac mitral valve surgery, such as advanced age (≥76 years), female gender, severely reduced LV-EF (<30%) and high logistic EuroScore (≥20%) were not predictive for mortality or major complication rates. In contrast, severely reduced renal function was predictive for adverse outcome. The TRAMI registry is the largest real world cohort of patients treated with MitraClip®. As long as randomized studies in this high-risk cohort of patients are lacking, TRAMI provides important information on outcomes after MitraClip® therapy. The data are important for hypothesis generation for randomized trials and TRAMI is an important tool for quality assurance after percutaneous mitral valve therapy in Germany.

Effects of different proton pump inhibitors on cardiac contractility in isolated human failing myocardium.

AIM: Proton pump inhibitors (PPI), e.g. pantoprazole (PP), esomeprazole (EP) and omeprazole (OP), work as anti-ulcer/gastrointestinal reflux drugs. Also, they are widely used in postoperative care of patients in cardiac surgery to prevent upper gastrointestinal bleeding. Therefore, in western industrial countries they play a major economic role, representing one of the most important drugs in open heart cardiac surgery. METHODS: Intact muscle strips (n=32) were isolated from the right ventricle wall of failing human hearts. In four different groups (PP, EP, OP, control group, each n=8), force amplitudes were recorded at a frequency of 60 beats per minute (bpm) with increasing PPI concentrations (0 to 320 µm/mL). RESULTS: In isometrically contracting muscle strips, significant negative inotropic effects were observed in the presence of all three PPI-groups (PP, EP and OP) with doses of 2.5 µg/mL and higher compared to the control group (p < 0.05 each). With high doses (320 µm/mL), force amplitudes could be almost completely depressed. The half maximal inhibitory concentration (IC50) for EP was 35.7 (confidence interval: 17.3-73.6) vs. OP 29.3 (6.8-126.6) vs. PP 25.1 (14.6-43.1) µg/mL (n.s.). No significant differences were found between the different proton pump inhibitors (PP, EP, OP) throughout the range of all concentrations. Relaxation was impaired in all PPI subgroups with prolonged time to 90% relaxation (RT90%) and maximum relaxation velocity (­df/dt) was reduced, too. These effects were partially reversible after wash-out of the drugs. CONCLUSION: We conclude that proton pump inhibitors show significant negative inotropic effects on isolated human failing myocardium. There is no apparent difference seen in the magnitude of the effects of each PPI-group. Further, in-vivo investigations are necessary to reveal the clinical evidence of PPI's negative inotropic effects, e.g. in cardio-surgical patients with heart failure.

Soilborne Pathogens of Cereals in an Irrigated Cropping System: Effects of Tillage, Residue Management, and Crop Rotation.

An irrigated cropping systems experiment was conducted for 6 years in east-central Washington State to examine agronomic and economic alternatives to continuous annual winter wheat (Triticum aestivum) with burning and plowing, and to determine how root diseases of cereals are influenced by management practices. The continuous winter wheat treatment with burning and plowing was compared with a 3-year no-till rotation of winter wheat-spring barley (Hordeum vulgare)-winter canola (Brassica napus) and three straw management treatments: burning, straw removal, and leaving the straw stubble standing after harvest. Take-all disease and inoculum increased from years 1 to 4 in the continuous winter wheat treatment with burning and plowing, reducing plant growth compared to the no-till treatments with crop rotations. Inoculum of Rhizoctonia solani AG-8 was significantly lower in the tilled treatment compared to the no-till treatments. Inoculum concentration of Fusarium pseudograminearum was higher than that of F. culmorum, and in one of three years, the former was higher in treatments with standing stubble and mechanical straw removal compared to burned treatments. Residue management method had no effect on Rhizoctonia inoculum, but spring barley had more crown roots and tillers and greater height with stubble burning. This 6-year study showed that irrigated winter wheat can be produced in a no-till rotation without major disease losses and demonstrated how cropping practices influence the dynamics of soilborne cereal diseases and inoculum over time.

[Recurrent familial cardiac myxomas and lentiginosis. Second recurrence in a 41-year-old female patient]. / Rezidivierende familiäre kardiale Myxome und Lentiginose. Zweites Myxomrezidiv bei einer 41-jährigen Patientin.

The case of a 41-year-old woman with recurrent cardiac myxomas and widespread lentiginosis is reported. The diagnosis of a Carney complex was established 7 and 25 years, respectively, after first manifestation of the cardiac myxomas in both the patient and her brother. This peculiar hereditary disease is commonly associated with multiple neoplasms and an endocrine overactivity, requiring a thorough examination of the patients and their relatives to detect additional typical manifestations.

First Report of Damping-Off of Canola Caused by Rhizoctonia solani AG 2-1 in Washington State.

In early September 2003, winter canola (Brassica napus L) cv. Inca was direct seeded into plots previously cropped with spring barley at the Washington State University Dryland Research Station at Lind, WA. Before planting, the plots received 80 mm of water by sprinkler irrigation, and 2 weeks later, volunteer barley was killed with Paraquat contact herbicide. In late September, 3 weeks after planting, canola seedlings exhibited postemergence damping-off and lesions on the hypocotyls, resulting in significant stand reductions. Rhizoctonia solani was isolated from infected hypocotyls using water agar amended with chloramphenicol (100 µg/ml). Cultures on potato dextrose agar produced dark brown colonies with dark brown microsclerotia. Three isolates were grown on autoclaved oat seed for 3 weeks in 1-liter Erlenmeyer flasks at 22°C, and colonized seed was air dried in a laminar flow hood, ground in a coffee grinder, and added to a Thatuna silt loam at 1% (w/w). The infested soil was placed into 4- × 20.5-cm plastic tubes and planted with five canola seeds per tube, five tubes per isolate. In the control treatment, soil was not infested. Plants were grown in a temperature-controlled room in a greenhouse at 16°C, 12-h light/dark. Isolates caused pre- and postemergence damping-off after 1 week, and the surviving seedlings had significantly less plant height and dry weight. Isolates were identified as AG 2-1 by pairing cultures with AG 8, 2-1, and 10 on agar-coated slides (1). Selected isolates were also identified as AG 2-1 by sequencing of the ITS 1 and 2 regions of the rDNA and matching them to sequences in GenBank. On a farm north of Pullman, WA in 2004, R. solani was isolated from soil in spring and winter wheat fields using a toothpick baiting method (2). R. solani was found primarily from sites previously cropped with winter and spring canola. These isolates were identified as AG 2-1 and five isolates were tested in the greenhouse, as described above, on canola (cv. Inca), lentil (Lens culinaris Medik. cv. Merrit), wheat (Triticum aestivum L. cv. Madsen), barley (Hordeum vulgare L. cv. Baronesse), pea (Pisum sativum L. cv. Stirling), and chickpea (Cicer arietinum L. cv. Sierra). Three of five isolates significantly reduced emergence of canola, and all isolates significantly reduced dry weight of canola seedlings and caused lesions on hypocotyls. None of the isolates reduced emergence of the other crops. All isolates reduced the dry weight of pea and three isolates reduced plant height. None of the isolates reduced the dry weight of lentil, chickpea, wheat, or barley. One of the isolates was also tested on Arabidopsis thaliana and found to be pathogenic. R. solani AG 2-1 has been reported as an important pathogen on canola in Canada and Australia, but has not been reported from the Pacific Northwest of the United States. R. solani AG 2-1 is also pathogenic on rapeseed, mustard, and subterranean clover and has been isolated from wheat, sugar beets, and potato (3). Canola is a minor rotation crop in cereal-based cropping systems in eastern Washington (1,600 ha in 2005), but there is increasing interest in this oilseed crop for biodiesel production. However, R. solani AG 2-1 may reduce stands and yield of canola. References: (1) W. C. Kronland and M. E. Stanghellini. Phytopathology 78:820, 1988. (2) T. C. Paulitz and K. L. Schroeder. Plant Dis.89:767, 2005. (3) B. Sneh et al. Identification of Rhizoctonia species. The American Phytopathological Society. St. Paul, MN, 1991.

Reduction of Rhizoctonia Bare Patch in Wheat with Barley Rotations.

Rhizoctonia bare patch caused by Rhizoctonia solani AG-8 is a major fungal root disease in no-till cropping systems. In an 8-year experiment comparing various dryland no-till cropping systems near Ritzville, WA, Rhizoctonia bare patch first appeared in year 3 and continued unabated through year 8. Crop rotation had no effect on bare patch during the first 5 years. However, from years 6 to 8, both soft white and hard white classes of spring wheat (Triticum aestivum L.) grown in a 2-year rotation with spring barley (Hordeum vulgare L.) had an average of only 7% of total land area with bare patches compared with 15% in continuous annual soft white wheat or hard white wheat (i.e., monoculture wheat). In years 6 to 8, average grain yield of both soft white wheat and hard white wheat were greater (P < 0.001) when grown in rotation with barley than in monoculture. Although both classes of wheat had less bare patch area and greater grain yield when grown in rotation with barley, monoculture hard white wheat was more severely affected by Rhizoctonia than soft white wheat. Soil water levels were higher in bare patches, indicating that roots of healthy cereals did not grow into or underneath bare patch areas. This is the first documentation of suppression of Rhizoctonia bare patch disease in low-disturbance no-till systems with rotation of cereal crops.

[Differential therapy of heart failure. Which drug for which patient?]. / Differenzialtherapie der Herzinsuffizienz. Welche Substanz für welchen Patienten?

The implementation of guidelines for medical therapy of heart failure may be problematic for the following reasons: 1. Elderly patients and women were underrepresented in large clinical trials which may limit their therapeutic impact in these patients. 2. Therapeutic decisions are influenced by co-morbidities like renal failure, obstructive airway disease (COLD, Asthma), stroke, and diabetes mellitus. We therefore discuss the differential therapy of heart failure in view of particular patient subgroups.

The functional effect of adenoviral Na+/Ca2+ exchanger overexpression in rabbit myocytes depends on the activity of the Na+/K+-ATPase.

OBJECTIVES: The functional consequences of Na+/Ca2+ exchanger (NCX) overexpression in heart failure have been controversially discussed. NCX function strongly depends on intracellular sodium which has been shown to be increased in heart failure. METHODS AND RESULTS: We investigated the Na+/K+-ATPase (NKA) inhibitor ouabain (0.5-16 micromol/l) in electrically stimulated, isotonically contracting adult rabbit cardiocytes overexpressing NCX after adenoviral gene transfer (Ad-NCX-GFP, 48 h culture time). Myocytes transfected with adenovirus encoding for green fluorescent protein (Ad-GFP) served as a control. Contractions were analyzed by video-edge detection. In the Ad-NCX-GFP group, the maximum inotropic response was significantly reduced by 50.7% (P<0.05). This was a result of an enhanced susceptibility to contracture after exposure to the drug (median concentration (25-75%): 4 (4-8) vs. 8 (6-16) micromol/l, P<0.05). When analyzing relaxation before contracture, the maximum relaxation velocity was reduced (0.15+/-0.04 vs. 0.27+/-0.04 microm/s, P<0.05) and the time from peak shortening to 90% of relaxation was increased (298+/-39 vs. 185+/-15 ms, P<0.05). No differences in systolic and diastolic parameters were observed with the Na+ channel modulator BDF9198 (1 micromol/l). CONCLUSIONS: Inhibition of NKA by ouabain induces a combined diastolic and systolic dysfunction in NCX overexpressing rabbit myocytes. This may be the consequence of cytoplasmic Ca2+ overload due to inhibition of forward mode or induction of reverse mode Na+/Ca2+ exchange. In end-stage failing human myocardium and during digitalis treatment this mechanism may be of major importance.