Outcomes after transcatheter aortic valve replacement in older patients.

BACKGROUND: The prevalence of aortic valve stenosis is increasing due to the continuously growing geriatric population. Data on procedural success and mortality of very old patients are sparse, raising the question of when this population may be deemed as "too old even for transcatheter aortic valve replacement (TAVR)." We, therefore, sought to evaluate the influence of age on outcome after TAVR and the impact of direct implantation. METHODS: The data of 394 consecutive patients undergoing TF-TAVR were analyzed. Patients were divided into four age groups: ≤75 (group 1, n = 28), 76-80 (group 2, n = 107), 81-85 (group 3, n = 148), and >85 (group 4, n = 111) years. Direct implantation was performed when possible according to current recommendations. Survival was evaluated by Kaplan-Meier analysis. RESULTS: Mortality at 30 days and 1 year was not significantly different between the four age groups (3.6 vs. 6.7 vs. 5.4 vs. 2.7% and 7.6 vs. 17 vs. 14.5 vs. 13%m respectively, log-rank p = 0.59). Direct implantation without balloon aortic valvuloplasty was more frequently performed on patients aged >85 vs. ≤85 years (33.3 vs. 14.1%, p < 0.001). the incidence of procedural complications frequently associated with advanced age (stroke, vascular complications) was not significantly increased in group 4. CONCLUSION: Outcome after TF-TAVR is comparable among different age cohorts, even in very old patients. Direct implantation simplifies the procedure and could therefore play a role in reducing the incidence of peri-interventional complications in patients of advanced age.

Feasibility of the Figure-of-8-Suture as Venous Closure in Interventional Electrophysiology: One Strategy for All?

Background: Venous vascular access with higher sheath size is common in interventional electrophysiology. In contrast to arterial vascular access, no dedicated closure devices exist for closure after venous access with higher sheath sizes. The Figure-of-8-Suture, an easy to apply suture, may be as a feasible approach for closure venous puncture. Our aim was to evaluate the feasibility of closure of femoral venous access. Methods: From November 2016 to February 2018, patients undergoing electrophysiological procedures, closure of left atrial appendage or patent foramen ovale were included. Until May 2017, manual compression was performed to achieve haemostasis at venous access site (control group). From May 2017, patients were treated with a Figure-of-8-Suture (treatment group, Figure 1). Turnaround time and incidence of vascular complications were compared between the two groups. Results: In total, 290 patients were included, 132 in the control group and 158 in the Figure-of-8-Suture group. Hemostasis after sheath removal was achieved in 100% of the cases in the control group by manual compression and in 98.7% of the cases with the Figure-of-8-Suture (p=0.2). Vascular complications were more common in the control group (6.8 vs. 1.3 %, p=0.01). Turnaround time was significantly lower in the Figure-of-8-Suture group (58.6 ± 14 vs. 77 ± 33.9 min, p=0.004). In a sub-analysis in obese patients with body mass index (BMI) ≥30 kg/m2 (Figure-of-8 n=45, controls n=35), vascular complications were significantly more common in the control group (9.4 vs 0%, p=0.045). Conclusion: The Figure-of-8-Suture is an easy-to-apply, effective approach for venous closure after electrophysiological procedures.

Safety and efficacy of clip-based vs. suture mediated vascular closure for femoral access hemostasis: A prospective randomized single center study comparing the StarClose and the ProGlide device.

OBJECTIVES: This study is the first head-to-head analysis of StarClose vs. ProGlide in patients undergoing 5F or 6F percutaneous coronary catheterization or peripheral artery interventions. BACKGROUND: The clip based StarClose and the suture mediated ProGlide vascular closure device are well established for femoral hemostasis in endovascular therapy. However, until now no prospective randomized study compared the safety and efficacy of the two devices. METHODS: This prospective, randomized, single-center study enrolled 505 patients (69.6 ± 11.2 years) resulting in 538 procedures due to more than one intervention in several patients: We analyzed 422 cardiac catheterization and 116 peripheral artery interventions via a common femoral artery access. Patients were randomized to StarClose or ProGlide (1:1). In-hospital complications (major bleeding, hematoma, pseudoaneurysm, vessel occlusion, and arteriovenous fistula) and device failure were recorded. The puncture site was assessed by ultrasound in all patients prior to discharge. RESULTS: Overall complication rate was 3.9%. There were more complications after utilization of StarClose compared to ProGlide (5.6 vs. 2.2%, P = 0.064), which was significant in adjusted logistic regression analysis with a 2.9-fold increased risk of complications for StarClose (P < 0.05). In the subgroup of coronary catheterizations there were significantly more complications for StarClose compared to ProGlide (1.4 vs. 5.2%, P < 0.05) with a 4.7-fold increased risk. Device failure rate was not significantly different between the two devices. CONCLUSION: In this first randomized trial comparing the two closure systems complication rate was higher for StarClose with equal efficacy compared to ProGlide. © 2017 Wiley Periodicals, Inc.

Comparison of coronary artery calcification, carotid intima-media thickness and ankle-brachial index for predicting 10-year incident cardiovascular events in the general population.

AIMS: To compare the predictive value of coronary artery calcification (CAC), carotid intima-media thickness (CIMT) and ankle-brachial index (ABI) in a primary prevention cohort depending on risk factor profile to determine which of the three markers improves cardiovascular (CV) risk discrimination best in which risk group. METHODS AND RESULTS: We quantified CAC, CIMT, and ABI in 3108 subjects (mean age 59.2 ± 7.7, 47.1% male) without prevalent CV diseases from the population-based Heinz Nixdorf Recall study. Associations with incident major CV events (coronary event, stroke, CV death; n = 223) were assessed during a follow-up period of 10.3 ± 2.8 years with Cox proportional regressions in the total cohort and stratified by Framingham risk score (FRS) groups. Discrimination ability was evaluated with Harrell's C. All three markers were associated with CV events (hazard ratio [95% confidence interval (CI)]: CAC: 1.31 (1.23-1.39) per 1-unit increase in log(CAC + 1) vs. CIMT: 1.27 (1.13-1.43) per 1 SD vs. ABI: 1.30 (1.14-1.49) per 1 SD, in FRS adjusted models). Considering reclassification, CAC lead to highest reclassification in the total cohort, while also for CIMT and ABI significant improvement in net-reclassification was observed [NRI (95% CI): CAC: 0.55 (0.42-0.69); CIMT: 0.32 (0.19-0.45); ABI: 0.19 (0.10-0.28)]. CONCLUSION: Coronary artery calcification provides the best discrimination of risk compared with CIMT and ABI, particularly in the intermediate risk group, whereas CIMT may be an alternative measure for reassurance in the low risk group.

Deactivation vs. asynchronous pacing - prospective evaluation of a protocol for rhythm management in patients with magnetic resonance conditional pacemakers undergoing adenosine stress cardiovascular magnetic resonance imaging.

BACKGROUND: Cardiovascular Magnetic Resonance (CMR) imaging with adenosine stress is an important diagnostic tool in patients with known or suspected coronary artery disease (CAD). However, the method is not yet established for CAD patients with pacemakers (PM) in clinical practice. A possible reason is that no recommendations exist for PM setting (paused pacing or asynchronous mode) during adenosine stress. We elaborated a protocol for rhythm management in clinical routine for PM patients that considers heart rate changes under adenosine using a test infusion of adenosine in selected patients. METHODS: 47 consecutive patients (mean age 72.3 ± 10,0 years) with MR conditional PM and known or suspected CAD who underwent CMR in clinical routine were studied in this prospective observational study. PM indications were sinus node dysfunction (SND, n = 19; 40,4%), atrioventricular (AV) block (n = 26; 55.3%) and bradyarrhythmia in permanent atrial fibrillation (AF, n = 2; 4.3%). In patients with SND, normal AV-conduction and resting HR >45 bpm at the time of CMR and in AF the PM was deactivated for the scan. In intermittent AV-block a test infusion of adenosine was given prior to the scan. All patients with permanent higher degree sinuatrial or AV-block or deterioration of AV-conduction in the adenosine test were paced asynchronously during CMR, in patients with preserved AV-conduction under adenosine the pacemaker was deactivated. CMR protocol included cine imaging, adenosine stress perfusion and late gadolinium enhancement. RESULTS: The adenosine test was able to differentiate between mandatory PM stimulation during CMR and safe deactivation of the device. In patients with permanent sinuatrial or AV-block (n = 11; 23.4%) or deterioration of AV conduction in the adenosine test (n = 5, 10.6%) asynchronous pacing above resting heart rate did not interfere with intrinsic rhythm, no competitive stimulation was seen during the scan. 10 of 15 (66,7%) patients with intermittent AV-block showed preserved AV-conduction under adenosine. As in SND and AF deactivation of the PM showed to be safe during CMR, no bradycardia was observed. CONCLUSION: Our protocol for rhythm management during adenosine stress CMR showed to be feasible and safe and may be recommended for pacemaker patients undergoing routine CMR.

Cardiac mapping and pulmonary vein isolation using a novel ablation catheter with tip minielectrodes.

BACKGROUND: Pulmonary vein isolation (PVI) is a standard treatment for atrial fibrillation (AF). Identification of gaps in the ablation line is difficult. Tip-ring electrograms from ablation catheters represent relative large areas of myocardial tissue. Recently, an ablation catheter with three minielectrodes (ME) on the catheter tip with closer interelectrode spacing was introduced. The aim of our study was to evaluate the novel electrodes during PVI. METHODS: PVI was performed with an irrigated ablation catheter equipped with conventional electrodes and three additional radial tip electrodes. Detection of pulmonary vein potentials (PVPs), local signal amplitude, amplitude reduction during ablation, and loss of capture after ablation were compared between the ME and the conventional tip-ring electrodes. RESULTS: Thirty-one patients (mean age 67.8 ± 10.3 years, 45.2 % men) were included. A total of 306 mapping/lesion points were analyzed. A PVP was significantly more often obtained with the ME compared to the conventional tip-ring electrodes (99.2% vs 83.5%, P < 0.001). Local amplitude was significantly higher on the ME (0.8 ± 0.6 mV vs 0.67 ± 0.46 mV, P  =  0.003). Amplitude reduction during 1 RF pulse was significantly greater on the ME (82.9 ± 19.5% vs. 61.8 ± 26.9%, P < 0.001). During pace mapping, loss of capture after 1 RF pulse was observed significantly more often on ME (98.3% vs 63.3%, P < 0.001). CONCLUSION: Signal amplitude is higher and sensitivity during PVP mapping and ablation is increased when ME are used. ME may facilitate catheter ablation of AF in the future.

Reverse Remodelling of the Atria After Treatment of Obstructive Sleep Apnoea with Continuous Positive Airway Pressure: Evidence from Electro-mechanical and Endocrine Markers.

BACKGROUND: Recent studies have suggested a strong association between obstructive sleep apnoea (OSA) and atrial fibrillation (AF). However, the impact of continuous positive airway pressure (CPAP) therapy on reverse atrial remodelling in patients with OSA is poorly understood. We aimed to determine the impact of CPAP therapy on total atrial conduction time measured by PA tissue Doppler imaging (TDI) interval in patients without history of AF. METHODS AND RESULTS: Thirty-five patients with first diagnosed OSA (group 1) and 20 reference patients without OSA (group 2) were prospectively enrolled. Group 1 was divided into 25 patients with starting CPAP therapy (intervention group) and 10 patients without CPAP therapy (control group). PA-TDI interval, measured by tissue Doppler imaging, and B-type natriuretic-peptide (BNP) were determined at baseline and repeated after 30 days in group 1. Patients with OSA had a significantly longer PA-TDI interval (131.4±16.0 ms vs. 120.1±6.4 ms, p<0.001) compared to reference patients. PA-TDI interval shortened significantly after 30 days of CPAP therapy (131±17.1 ms vs. 124.6±15.7 ms, p<0.001), whereas no significant change was found in the control group (132.6±13.6 ms vs. 133.2±13.1 ms, p=0.31) and BNP-levels decreased significantly (39.1±50.7 pg/ml vs. 28.2±42.4 pg/ml, p<0.01), while BNP-levels remained unaffected after 30 days in control group (31.5±20 pg/ml vs. 34.4±20.5 pg/ml, p=0.41). CONCLUSIONS: Change in PA-TDI interval, as an indirect surrogate marker of atrial remodelling, suggests reverse atrial remodelling in patients with OSA and treated by CPAP. This effect may ensue from decreased atrial pressure or volume overload, as indicated by significantly reduced BNP levels. These observations suggest that the substrate pre-disposing to AF may be reversible and moreover can be measured by PA-TDI interval and BNP.

Feasibility and safety of adenosine cardiovascular magnetic resonance in patients with MR conditional pacemaker systems at 1.5 Tesla.

BACKGROUND: Cardiovascular Magnetic Resonance (CMR) with adenosine stress is a valuable diagnostic tool in coronary artery disease (CAD). However, despite the development of MR conditional pacemakers CMR is not yet established in clinical routine for pacemaker patients with known or suspected CAD. A possible reason is that adenosine stress perfusion for ischemia detection in CMR has not been studied in patients with cardiac conduction disease requiring pacemaker therapy. Other than under resting conditions it is unclear whether MR safe pacing modes (paused pacing or asynchronous mode) can be applied safely because the effect of adenosine on heart rate is not precisely known in this entity of patients. We investigate for the first time feasibility and safety of adenosine stress CMR in pacemaker patients in clinical routine and evaluate a pacing protocol that considers heart rate changes under adenosine. METHODS: We retrospectively analyzed CMR scans of 24 consecutive patients with MR conditional pacemakers (mean age 72.1 ± 11.0 years) who underwent CMR in clinical routine for the evaluation of known or suspected CAD. MR protocol included cine imaging, adenosine stress perfusion and late gadolinium enhancement. RESULTS: Pacemaker indications were sinus node dysfunction (n = 18) and second or third degree AV block (n = 6). Under a pacing protocol intended to avoid competitive pacing on the one hand and bradycardia due to AV block on the other no arrhythmia occurred. Pacemaker stimulation was paused to prevent competitive pacing in sinus node dysfunction with resting heart rate >45 bpm. Sympatho-excitatory effect of adenosine led to a significant acceleration of heart rate by 12.3 ± 8.3 bpm (p < 0.001), no bradycardia occurred. On the contrary in AV block heart rate remained constant; asynchronous pacing above resting heart rate did not interfere with intrinsic rhythm. CONCLUSION: Adenosine stress CMR appears to be feasible and safe in patients with MR conditional pacemakers. Heart rate response to adenosine has to be considered for the choice of pacing modes during CMR.

Total atrial conduction time assessed by tissue doppler imaging (PA-TDI Interval) to predict early recurrence of persistent atrial fibrillation after successful electrical cardioversion.

BACKGROUND: The aim of this study was to investigate whether total atrial conduction time (TACT) assessed via tissue Doppler imaging (PA-TDI interval) can identify patients with early recurrent atrial fibrillation (ERAF) after successful direct-current electrical cardioversion (CV) of persistent atrial fibrillation (persPAF). METHODS AND RESULTS: A total of 54 patients without antiarrhythmic drug medication (mean ± SD: 66 ± 10.4 years; 33% women) with persPAF and successful CV were enrolled between May 2012 and May 2013. TACT was measured 6 hours after successful CV in the left atrium by tissue Doppler imaging (PA-TDI interval). ERAF was determined via Holter-electrocardiogram over a period of 7 days after CV. Receiver opearting characteristic analysis was used to determine an optimal cutoff value of PA-TDI interval for prognosis of ERAF. Based on this result, recurrence-free survival was assessed with Mantel-Haenszel's log-rank test. ERAF occurred in 23 patients (43%). PA-TDI interval was longer in patients with ERAF compared to those who maintained sinus rhythm (mean ± SD: 163.5 ± 11.1 vs 132.3 ± 11.2 milliseconds; P < 0.00001). At the cutoff value of 152 milliseconds, PA-TDI interval sensitivity and specificity related to ERAF were 87% and 100%, respectively. CONCLUSION: Measuring PA-TDI interval may help to predict ERAF after successful CV in patients with persAF.

Comparison of collagen-based vascular closure devices in patients with vs. without severe peripheral artery disease.

PURPOSE: To compare complication rates of a collagen-based vascular closure device (VCD) in patients with vs. without significant peripheral artery disease (PAD). METHODS: A total of 382 patients (268 men; mean age 64.6±10.8 years) undergoing either an endovascular procedure of the lower limb (PAD group, n=132) or a percutaneous coronary intervention (PCI group, n=250) via a common femoral artery access were enrolled in this prospective study if hemostasis was achieved using the collagen-based Angio-Seal. In the PCI group, significant PAD was excluded by measurement of the ankle-brachial index. In-hospital major complications (bleeding, large hematoma, pseudoaneurysm, vessel occlusion, dissection) were recorded. RESULTS: Similar and low rates of major complications were observed in both arms of the study: 2 (1.5%) major complications in the PAD group and 3 (1.2%) in the PCI group (p=1.0). There was no significant difference in efficacy of the VCDs in the groups (PAD group 99.2% vs. 100% in PCI group, p=0.35). CONCLUSION: Our study shows no significant differences in the rate of major complications after utilization of a collagen-based VCD for femoral artery access site closure in patients with severe lower limb PAD compared to those without; however, complications in the PAD group tended to be more severe, with the need for surgical repair.

Safety and effectiveness of a novel vascular closure device: a prospective study of the ExoSeal compared to the Angio-Seal and ProGlide.

PURPOSE: To prospectively assess the safety and efficacy of a novel absorbable vascular closure device (ExoSeal) in patients undergoing cardiac catheterization with femoral access compared to the established collagen-based (Angio-Seal) and suture-mediated (ProGlide) closure devices. METHODS: This prospective, observational, dual-center, non-randomized, non-blinded study enrolled 1013 patients (65.1 ± 11.8 years) undergoing cardiac catheterization via a common femoral artery access in which hemostasis was achieved using a vascular closure device (255 Angio-Seal, 258 ProGlide, and 500 ExoSeal). In hospital complications (bleeding, hematoma, pseudoaneurysm, vessel occlusion, dissection, and arteriovenous fistula) of the puncture site and device failures (persistent bleeding) were recorded and compared for ExoSeal vs. the established devices (Angio-Seal + ProGlide). RESULTS: There were more complications after utilization of ExoSeal compared to established devices (3.6% vs. 1.2%, p=0.012). No significant difference was observed in the device success rate between the established vascular closure devices (96.3%) and the novel device (94.8%, p=0.28). Considering each closure system, Angio-Seal had the lowest complication rate (0.4%) and the highest efficacy (99.2%); the latter differed significantly from ExoSeal (94.8%, p=0.001). Logistic regression analysis revealed a >3-fold odds of complications when using ExoSeal, which remained unchanged in multivariate analysis. CONCLUSION: Utilization of the novel vascular closure device is associated with a higher complication rate and a similar device failure rate compared to collagen-based and suture-mediated devices, with Angio-Seal having the lowest complication and device failure rates.

P wave dispersion and QT dispersion in adult Turkish migrants with familial mediterranean fever living in Germany.

BACKGROUND: Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disease associated with subclinical inflammation, which includes atherosclerosis arising from endothelial inflammation, which in turn increases the risk of atrial or ventricular arrhythmias. Conduction abnormalities can be detected using the electrocardiographic (ECG) indices P and QT dispersion (Pdisp and QTdisp). Currently, it is unknown whether patients with FMF are more likely to have abnormalities of these ECG indices. Moreover, existing studies were conducted in countries with higher FMF prevalence. We therefore perform the first prospective study assessing Pdisp and QTdisp in adult FMF patients in Germany, where prevalence of FMF is low. METHOD: Asymptomatic FMF patients (n=30) of Turkish ancestry living in Germany and age-matched healthy controls (n=37) were prospectively assessed using 12-lead ECG. RESULTS: Patients and controls were comparable in gender and body mass index, and patients had higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum amyloid A (SAA) compared to controls (ESR: 23.7±14.3 vs. 16.1±13,3 mm/1(st)h, p=0.03, CRP: 0.73±0.9 vs. 0.26±0.4 g/dl, p=0.01, SAA: 3.14±4,8 vs. 0.37±0.3 mg/dl, p<0.01). No statistically significant difference between patients and controls respectively, for Pdisp (43.7±11.9 vs. 47.1±11.2ms, p=0.23), QTdisp (65.9±12.3 vs. 67.6±12.7 ms, p=0.58) or corrected QTdisp (cQTdisp: 73.9±15.0 vs. 76.0±13.3 ms, p=0.55) was found. No correlation could be found between Pdisp or QTdisp or cQTdisp and any of the biochemical markers of inflammation. CONCLUSION: FMF patients living in Germany show a Pdisp and QTdisp comparable to healthy controls, with no increased risk of atrial or ventricular arrhythmias indicated.

Monitoring ASA and P2Y12-specific platelet inhibition--comparison of conventional (single) and multiple electrode aggregometry.

OBJECTIVE: Several platelet function test systems exist for the evaluation of the platelet inhibitory effect in patients on P2Y12 inhibitors and/or acetylsalicylic acid (ASA, aspirin) therapy. Studies comparing different available assays found only a poor correlation. The objective of the present study was to evaluate the correlation and agreement between single electrode (SEA) and multiple electrode (MEA) aggregometry. METHODS AND RESULTS: In whole blood arachidonic acid (AA) and adenosine diphosphate (ADP)-induced platelet aggregation was measured simultaneously using SEA (Chrono-Log) and MEA (Multiplate). We analyzed a total of 226 measurements taken from 58 patients on single ASA therapy or dual antiplatelet therapy with ASA and a thienopyridine. A cut-off value for clopidogrel/prasugrel high on-treatment platelet reactivity (HPR) of > 47 units (U) was chosen for MEA testing using hirudin and > 5 Ohm for SEA with citrate anticoagulated blood samples. The respective cut-off values for ASA HPR were > 30 U for the MEA assay and > 1 Ohm for SEA testing. There was a good correlation of the prevalence of thienopyridine-HPR in both whole blood assays (Spearman rank correlation coefficient r = 0.698) and a good inter-rate accordance (Cohen's Kappa statistic κ = 0.648). For AA-induced aggregation, the correlation of the results obtained was significant (r = 0.536; p < 0.001) and detecting ASA-HPR revealed a moderate (κ = 0.482) correlation between both impedance aggregometry assays. CONCLUSION: Platelet function testing using SEA and MEA provided both good accordance and correlation and therefore study results obtained by these two assays similarly enabled the detection of HPR of thienopyridine (and ASA) therapy.

Left atrial size quantification using non-contrast-enhanced cardiac computed tomography - association with cardiovascular risk factors and gender-specific distribution in the general population: the Heinz Nixdorf Recall study.

BACKGROUND: Left atrial (LA) size is associated with cardiovascular mortality and morbidity. Once cardiac computed tomography (CT) is performed, information on LA size is readily available without additional contrast media or radiation exposure. PURPOSE: To determine the association of CT-derived LA area and body surface area-adjusted (BSA) LA index with cardiovascular risk factors and describe age- and gender-specific normative values in a general population cohort. MATERIAL AND METHODS: This study included 3945 participants (mean age, 59 ± 8 years; 53% women) from the community-based Heinz Nixdorf Recall Study. LA area in an axial image at the level of the mitral valve was quantified from non-contrast-enhanced electron-beam CT by manual delineations of the boundaries of the LA with exclusion of subjects with prevalent cardiovascular disease. Definition of normative values was performed in subjects without predictors of LA enlargement. RESULTS: LA quantification was feasible in all subjects. Men had larger LA size (1856 mm(2) vs. 1677 mm(2), P < 0.0001), while after adjustment for BSA, this effect was inverted (910 mm(2)/m(2) vs. 933 mm(2)/m(2) for men and women, P < 0.0001). Determinants of body size were major predictors of LA size (body mass index [BMI]: R(2) = 0.195, BSA: R(2 )= 0.216, both P < 0.0001). Blood pressure was associated with LA size (parameter-estimate [95% confidence interval] = 51.0 (4.9-57.1) mm(2)/10 mmHg for systolic, 31.4 (25.4-37.4) mm(2)/5 mmHg for diastolic blood pressure, 214.6 (186.9-242.3) mm(2) for antihypertensive medication, P < 0.0001 for all). Cholesterol levels, lipid-lowering therapy, and diabetes were associated with LA in univariable analysis, however, correlations were low (r(2 )≤ 0.026). Current smoking was associated with reduced LA size (-115.9 [-149.0 - -82.8] mm(2), P < 0.0001). In multivariable regression, BMI, blood pressure, antihypertensive medication, and smoking remained associated with LA size (P < 0.005). CONCLUSION: Non-contrast-enhanced cardiac CT enables LA quantification with body size, hypertension, and smoking status being predictors of LA size.

Impact of socioeconomic and cardiovascular risk factors on the effect of genetic variants associated with NT-proBNP.

N-terminal prohormone of brain natriuretic peptide (NT-proBNP) is an established biomarker for diagnosis of heart failure. The study aims to explore whether known cardiovascular risk factors, including education and income as indicators of socioeconomic position (SEP), may interact with the genetic effect of NT-proBNP-related single nucleotide polymorphisms (SNP) to influence plasma levels of NT-proBNP in a population-based study sample. Information on effect alleles of three SNPs previously reported to be related to NT-proBNP was combined individually for 4,520 participants of the Heinz Nixdorf Recall Study to calculate a genetic risk allele sum score (GRSNT-proBNP). Linear Regression models were used to examine the association of cardiovascular risk factors and GRSNT-proBNP with log-transformed NT-proBNP levels, as well as cardiovascular risk factor by GRSNT-proBNP interactions. The GRSNT-proBNP was associated with NT-proBNP showing 1.13-fold (95% CI 1.10-1.16) higher plasma levels per additional effect allele. Interaction terms included in the regression models gave some indication for interaction of the GRSNT-proBNP with the SEP indicator income as well as with C-reactive protein. In regression models stratified by income quartiles the strongest genetic effect was observed in the third income quartile showing 1.18-fold (95% CI 1.12-1.25) higher average NT-proBNP levels per additional allele compared to the lowest income quartile with 1.08-fold (95% CI 1.01-1.15) higher NT-proBNP levels. The results of the present study indicate that genetic effects of NT-proBNP increasing alleles are stronger in higher SEP groups. This may be due to a stronger influence of non-genetic cardiovascular risk on NT-proBNP in low SEP groups.

Socioeconomic position is associated with N-terminal pro-brain natriuretic peptide (NT-proBNP)-Results of the population-based Heinz Nixdorf Recall study.

OBJECTIVES: N-Terminal pro Brain Natriuretic Peptide (NT-proBNP) is a diagnostic marker for heart failure and a prognostic factor for cardiovascular disease (CVD). The aim of this study was to examine the association of socioeconomic position (SEP) with NT-proBNP while assessing sex-differences and the impact of CVD risk factors and prevalent CVD on the association. METHODS: Baseline data of 4598 participants aged 45-75 years of the Heinz Nixdorf Recall Study were used. Income and education were used as SEP indicators. Age- and sex-adjusted linear regression models were fitted to calculate effect size estimates and 95% confidence intervals (95%-CIs) for the total effect of SEP indicators on NT-proBNP, while potential mediation was assessed by additionally accounting for traditional CVD risk factors (i.e., systolic blood pressure, HDL cholesterol, LDL cholesterol, diabetes, anti-hypertensive medication, lipid-lowering medication, BMI, current smoking). Education and income were included separately in the models. RESULTS: With an age- and sex-adjusted average change in NT-proBNP of -6.47% (95%-CI: -9.91; -2.91) per 1000€, the association between income and NT-proBNP was more pronounced compared to using education as a SEP indicator (-0.80% [95%-CI: -1.92; 0.32] per year of education). Sex-stratified results indicated stronger associations in men (-8.43% [95%-CI: -13.21; -3.38] per 1000€; -1.63% [95%-CI: -3.23; -0.001] per year of education) compared to women (-5.10% [95%-CI: -9.82; -0.01] per 1000€; -1.04% [95%-CI: -2.59; 0.50] per year of education). After adjusting for CVD risk factors some of the observed effect size estimates were attenuated, while the overall association between SEP indicators and NT-proBNP was still indicated. The exclusion of participants with prevalent coronary heart disease or stroke did not lead to a substantial change in the observed associations. CONCLUSIONS: In the present study associations of education and income with NT-proBNP were observed in a population-based study sample. Only parts of the association were explained by traditional CVD risk factors, while there were substantial sex-differences in the strength of the observed association. Overt coronary heart disease or stroke did not seem to trigger the associations.

NT-proBNP for risk prediction of cardiovascular events and all-cause mortality: The getABI-study.

BACKGROUND: Beside their role in the diagnosis of heart failure in symptomatic patients with dyspnea, natriuretic peptides have been suggested to improve risk prediction of cardiac events and mortality in asymptomatic cohorts. We aimed to evaluate the prognostic value of NT-proBNP for cardiovascular and all-cause mortality above traditional risk factors in a prospective cohort study of unselected elderly patients in a representative primary care setting. METHODS: We followed 6382 patients of the getABI-study for 7 years. Associations of NT-proBNP levels (≤125; 125-300; >300pg/ml for all) with all-cause and cardiovascular mortality were assessed using cox regression analysis. RESULTS: The incidence of all-cause and cardiovascular mortality was higher in subjects with higher levels of NT-proBNP (all-cause mortality/cardiovascular mortality: 35.4%/6% for NT-proBNP > 300 pg/ml; 16.2%/40% for NT-proBNP 125-300 pg/ml vs. 11.4%/4% for NT-proBNP ≤ 125 pg/ml. Participants with a NT-proBNP levels > 300pg/ml had increased incidence of hard endpoint (hazard ratio (HR) (95% confidence interval (CI)): 3.62 (3.15-4.17) for all-cause mortality, and 6.38 (4.84-8.41) for cardiovascular mortality). These associations remained after adjustment for traditional risk factors and cardiac medications and diseases (HR = 2.64 (2.26-3.08) for all-cause mortality, and HR = 3.93 (2.90-5.32) for cardiovascular mortality). CONCLUSION: Our results show strong associations of higher NT-proBNP levels with cardiovascular and all-cause mortality in an unselected, large population of elderly patients in the primary care setting independent of traditional risk factors indicating that NT-proBNP can help identifying subjects at high risk for cardiac events.

Undersizing but overfilling eliminates the gray zones of sizing for transcatheter aortic valve replacement with the balloon-expandable bioprosthesis.

BACKGROUND: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing. METHODS: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics. RESULTS: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physicians choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005). CONCLUSION: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.

First data on cardiac mapping and outcome of pulmonary vein isolation using a novel ablation catheter with tip mini electrodes.

AIMS: Pulmonary vein isolation (PVI) is a standard treatment of atrial fibrillation (AF). AF recurrence after PVI occurs in a substantial number of cases. A novel ablation catheter equipped with mini-electrodes (ME) may facilitate PVI. Our study evaluated outcome after PVI with the ME catheter compared to a standard catheter. METHODS: Patients undergoing PVI with the ME catheter were compared to a control group ablated with a standard contact force sensing catheter. Freedom of AF after 12 months was the study endpoint. Additionally, low voltage areas (LVA) <0.5 mV were identified with a circular mapping catheter (CMC) and the ablation catheter in each group. LVA were compared between the maps obtained with the CMC and the ME or standard catheter, respectively. RESULTS: A total of 110 patients underwent PVI with ME catheter (n = 59) or the standard catheter (n = 51). Procedure duration (117.4 ±â€¯43 vs. 103.1 ±â€¯32.8 min, p = 0.15), radiation dose (1135.6 ±â€¯1125.7 vs. 1078.8 ±â€¯951.4 µGy/m2, p = 0.91), incidence of complications and 12-month success rate (64.4 vs 72.5%, p = 0.36) were not significantly different between the groups. LVA were significantly smaller when obtained with the standard catheter compared to the CMC (14 ±â€¯13 vs. 58.5 ±â€¯22.1 cm2, p < 0.001), while no such difference was seen for mapping with the ME compared to the CMC (37 ±â€¯30.3 vs. 33.4 ±â€¯39 cm2, p = 0.4). CONCLUSION: Clinical outcomes are comparable between ME catheter and a standard contact force sensing catheter. Furthermore, better LVA detection points to improved mapping capabilities of the ME catheter.

Assessment of Systemic Adenosine Effect Using Color Doppler Ultrasound of the Splenic Artery-Feasibility and Potential Clinical Utility for Coronary Interventions.

Adenosine induces coronary vasodilation and simultaneously reduces splanchnic perfusion. This effect can be absent in adenosine non-responders. Imaging of splanchnic arteries under adenosine assessing this effect has not been performed in humans previously. In 26 patients, splenic artery color Doppler was performed during an infusion of adenosine. Peak velocity in the splenic artery was measured before the infusion and at 2 min. Results were compared qualitatively with perfusion imaging in magnetic resonance. A total of 24 patients showed a drop of splenic artery peak velocity from 62.3 ± 18.1 to 40.4 ± 15.7 cm/s (p <0.001), which corresponded to perfusion restriction in magnetic resonance. Two patients with constant splenic artery velocity did not show perfusion restriction. We showed feasibility of assessing changes in splenic artery velocity under adenosine for the first time in humans. Further studies are needed to investigate whether this novel application is a robust tool to rule out inadequate adenosine effect during measurement of fractional flow reserve in coronary catheterization.