Feasibility of multiplane microtransoesophageal echocardiographic guidance in structural heart disease transcatheter interventions in adults.

INTRODUCTION: Structural heart interventions are guided by transoesophageal or intracardiac echocardiography (TEE/ICE). MicroTEE, developed for paediatric purposes, is smaller and therefore less invasive and traumatic, avoiding the need for general anaesthesia. We aimed to show feasibility of procedural guidance by comparing image quality of microTEE with standard TEE and ICE during adult transcatheter interventions, and assess the accuracy in obtaining left atrial appendage (LAA) measurements between the microTEE probe and standard TEE. METHODS AND RESULTS: We prospectively included 49 patients (20 women, 64 ± 18 years). Intraprocedural images were obtained by using the microTEE probe and standard (2D and 3D) TEE (LAA closure, MitraClip implantation) or ICE (interatrial communication closure, transseptal puncture for left atrial ablation). Two echocardiographers independently assessed image quality from 1 (excellent) to 4 (poor) and performed LAA measurements. Use of microTEE was not related to significant discomfort. Image quality obtained with the microTEE probe was lower than with standard TEE (2 [1-2] vs. 1 [1-2]; p = 0.04) and comparable with ICE images (2 [1-2] vs. 2 [1-2], p = 0.13). MicroTEE showed a wider field of view than ICE. LAA measurements on images obtained by microTEE were strongly associated with standard TEE. CONCLUSIONS: MicroTEE seems feasible for guidance during transcatheter heart interventions in adults. MicroTEE imaging offers a wider field of view than ICE, and its accuracy is comparable with TEE. In transcatheter interventions performed under conscious sedation, microTEE might be a viable and advantageous alternative to standard TEE or ICE.

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.

A novel technique to remove a right atrial thrombotic mass attached to a patent foramen ovale (PFO) closure device.

Any percutaneously implanted foreign device carries the potential risk of thrombus formation. If a thrombus is detected after device implantation during follow-up, in most cases anticoagulation therapy is sufficient to resolve the thrombus. If the anticoagulation concept fails, surgery has been the only alternative option to remove thrombotic masses. This case of a patient with a large thrombus formation attached to a PFO closure device who denied surgery demonstrates that mechanical percutaneous clot retrieval is feasible with the AngioVac aspiration system (Vortex Medical, Inc., Norwell, MA). © 2013 Wiley Periodicals, Inc.

Acute and long-term results of carotid stenting under proximal embolic protection using the Gore Flow Reversal System.

OBJECTIVE: This study evaluates short- and long-term results of CAS with the Gore Flow Reversal System (GFRS). BACKGROUND: Embolic protection devices are of fundamental importance in carotid artery stenting (CAS). Proximal protection has potential advantages compared with distal protection. Limited data are available regarding the safety of the proximal GFRS. METHODS: CAS was performed with the GFRS. Patients' neurological status was assessed during the intervention and at follow-up. Results of patients treated before 2006 were also compared to those of patients treated after 2006 because of changes in device design. RESULTS: CAS was performed in 86 patients with 87 stenoses (symptomatic in 37%). The procedure was technically successful in all cases. In 11 patients a transient periprocedural neurologic deficit occurred related to temporary cerebral flow compromise during balloon occlusion with complete resolution at completion of the procedure. The stroke/death rate at one month was 2.3% with a combined ipsilateral stroke and death rate at one year of 4.6%. There was no significant difference in event rates between the newer and older device version. Overall follow-up time was 484 ± 3.4 patient years with a range of 0 to 119 months. The average yearly ipsilateral stroke rate including the first 30 days was 0.96%. CONCLUSION: Our results demonstrate that CAS using the GFRS is safe whether the original or new device versions were used. The periprocedural stroke rate is at least as low as the stroke rate reported using distal protection. The long-term stroke rate after CAS is low.

Percutaneous approaches to mitral valve regurgitation.

Mitral regurgitation is a common problem associated with significant morbidity and mortality. Mitral valve surgery has been the treatment of choice for symptomatic patients with severe mitral regurgitation or asymptomatic patients with high-risk clinical features. However, a significant number of patients remain untreated related mainly due to a projected high surgical risk. Therefore, alternative percutaneous treatments including indirect annuloplasty, which takes advantage of the coronary sinus, and direct annuloplasty have recently been explored. Most recently, promising results of the first randomized trial comparing conventional mitral valve surgery to percutaneous therapy with a clip creating a double orifice much like the surgical Alfieri approach have been presented. Finally, percutaneous mitral valve replacement in an animal model has been pursued. This review serves to familiarize the reader with some anatomical concepts and devices for percutaneous mitral repair.

Catheter-based renal sympathectomy.

The sympathetic nervous system via its effect on the kidney maintains a key role in blood pressure regulation and in the pathogenesis of hypertension. In turn, the kidney receives a dense innervation of afferent sympathetic fibers allowing it to effectively modulate the sympathetic tone. Hence, the kidney can be both culprit and victim of increased sympathetic activity. In addition, conditions such as congestive heart failure, chronic renal failure or the metabolic syndrome are associated with an increased sympathetic activity whether or not hypertension is present. On this account, both the sympathetic nervous system and the kidney were identified as potential therapeutic targets in the treatment of hypertension and other conditions associated with a high sympathetic tone. Initial investigations focused on surgical removal of the sympathetic trunk, unfortunately accompanied by operative mortality and major side effects. More specific methods of disrupting interactions between the sympathetic nervous system and the kidneys were subsequently explored including the removal of diseased kidneys and, more recently, minimally invasive severance of the renal sympathetic nerves. Currently, most hypertensive patients can be treated by effective antihypertensive drugs. Notwithstanding, a small group of hypertensive patients remains suboptimally controlled despite identification of potential causes and appropriate treatment. In this group an elevated sympathetic tone may be a significant contributor to treatment resistance and selective renal sympathectomy may be beneficial. The role of the sympathetic nervous system in blood pressure control and the effect of selective sympathectomy are discussed in this review.

Transcatheter closure of patent foramen ovale, atrial septal defect and left atrial appendage.

Intracardiac defects such as atrial septal defect (ASD) and patent foramen ovale (PFO) are common forms of congenital intracardiac apertures which can be successfully closed percutaneously. Since the initial description of an atrial septal defect closure device in the mid 1970s by King and Mills, transcatheter closure of atrial septal defects and patent foramen ovale using various devices has now become an established practice in many centers. The left atrial appendage is a trabeculated remnant of the embryonic left atrium. This is an important source of emboli related to atrial fibrillation. Closure of the left atrial appendage is designed to reduce the risk of stroke in patients with atrial fibrillation. This article reviews the current indications and latest developments in catheter closure of PFO, ASD and left atrial appendage.

A gelatin in situ-overlay technique localizes brain matrix metalloproteinase activity in experimental focal cerebral ischemia.

To determine the activity of matrix metalloproteinases (MMP), especially MMP-2 and MMP-9, which play an important role in ischemic stroke and intracerebral hemorrhage, we adapted a simple and rapid method for localizing gelatinase activity to a gelatin film in situ-overlay technique previously used in cancer research. Ten micrometer cryosections of rat brain from controls and animals subjected to 3 h of ischemia and 48 h of reperfusion (suture model for transient cerebral ischemia) were used. After thawing, a gelatin film with a polyester base was put on the slide, incubated for 24 h at 37 degrees C, stained with Ponceau S, and then discolored in bi-distilled water. Non-staining areas on the film corresponded to lysis zones, caused by activated MMPs. This was proven by MMP incubation at various concentrations on the plain gelatin film and pretreatment with EDTA (an MMP inhibitor), which prevents lysis zones in normal and ischemic brains. As confirmatory tests, SDS-PAGE zymography was used to define MMP activity, and also MMP-2 immunohistochemistry to detect the possibly cellular origin of MMPs. Normal rat brain exhibited a low background activity, which was visible as a light halo-like lysis zone over and around the brain. Areas in normal brain with medium MMP activity were within the white matter (corpus callosum, anterior commissure, and cerebellum). Ischemic brain exhibited high activity lysis zones within the infarcted area (detected by microtubuli associated protein-2 staining). These zones consisted of microscopically small lysis holes with a diameter of about 10-20 microm. Immunohistochemistry showed that especially microvessels expressed MMP antigen. SDS-PAGE zymography differentiated between a high level of activated MMPs in the ischemic area and a low level in the non-ischemic basal ganglia. The gelatin film in situ-overlay technique is able to localize MMP activity in ischemic rat brain tissue on a microscopic level.

Contractile function of papillary muscle from rats with different infarct size after beta-adrenergic blockade and ACE-inhibition.

We tested whether ACE-inhibition with ramipril (A), beta-adrenergic blockade with metoprolol (beta) or combined treatment (beta A) for 6 weeks after inducing myocardial infarction in rats by left coronary artery ligation modifies contractile function of hypertrophied papillary muscle from left ventricles with different infarct size (IS) compared to a placebo group (P). At IS<40% of left ventricle, contraction and relaxation were less impaired than at IS>40% compared to sham operated rats (SO). Isometrically developed peak force and calcium sensitivity of myofilaments, measured in skinned fibres, were significantly higher in beta. Treatment with ramipril or metoprolol improved contraction rate and force development, respectively, mainly at IS<40%, but deteriorated relaxation rate. ACE-inhibition and beta-adrenergic blockade had no significant improving effect on the relaxation rate and further characteristics of the contractile function at IS>40%, although combined treatment reduced the infarct size and ramipril treatment suppressed the development of hypertrophy. Post-extrastimulatory potentiation was increased in beta and beta A at IS>40%. Post-rest potentiations were influenced hardly at IS<40% and were significantly smaller in A at IS>40%. The twitch-to-twitch decay of the potentiations was faster at IS>40%. Increase in the degree of post-extrastimulatory potentiation, steeper twitch-dependent decay of the potentiations and loss of rest-dependent potentiation at IS>40% indicate relatively increased trans-sarcolemmal Ca2+ transports via Ca2+ channels and Na+/Ca2+ exchange, partly modified by ramipril and metoprolol. The results demonstrate that ACE-inhibition and beta-adrenergic blockade induce a dissociation between trophic effects and phenotypic effects on contractile function after chronic infarction.

Cholic acid and ursodeoxycholic acid therapy in primary biliary cirrhosis. Changes in bile acid patterns and their correlation with liver function.

We treated 6 patients with Stage II primary biliary cirrhosis with cholic acid (CA) 10 mg.kg-1 per day for 3 months and then with the same dose of ursodeoxycholic acid (UDCA). A matching group of 6 patients was observed for 3 months without any therapy. Liver function tests and serum and stool bile acids were investigated before, during and at the end of CA and UDCA therapy. The results of liver function tests deteriorated after 6-8 weeks of CA therapy and the changes were correlated (r = 0.92) with an increase in alpha-dihydroxy-bile acids (chenodeoxycholic acid and deoxycholic acid) in the serum. The 24 h excretion of DCA in 24 h faeces was markedly increased. Ursodeoxycholic acid treatment improved liver function tests; after 4 weeks glutamate dehydrogenase (GLDH) had decreased. After 8-12 weeks of therapy ursodeoxycholic acid had increased to 50-60% of the total serum bile acids whereas the more apolar bile acids were significantly decreased. No changes in liver function tests or bile acid metabolism were found in the untreated group. Since CA and UDCA are non-toxic in man, this trial indicates that the apolar bile acids chenodeoxycholic acid and deoxycholic acid may be responsible for the deterioration of liver function in primary biliary cirrhosis. However, the therapeutic effect of UDCA cannot be explained merely by the decrease in alpha-dihydroxy-bile acids in the serum, since the laboratory results had improved prior to the decrease in the serum apolar bile acids.