Technique of interventional repair in adult aortic coarctation.

Surgical treatment of aortic coarctation has increased life expectancy and reduced mortality. Unfortunately, the average lifespan after repair remains only 35 to 50 years, and significant morbidity persists as a result of aneurysm formation, hypertension, accelerated coronary disease, and stroke. Follow-up studies have revealed restenosis rates of 30% and persistent hypertension at rest and during exercise, sometimes with compromised cardiac function. The less invasive nature of nonsurgical repair using transcatheter therapies has led to balloon angioplasty and, recently, stent implantation as an emerging concept for the treatment of aortic coarctation. This review focuses on advances in the management, current indication, and techniques of interventional repair in aortic coarctation.

Renal Insufficiency Following Radiocontrast Exposure Trial (REINFORCE): a randomized comparison of sodium bicarbonate versus sodium chloride hydration for the prevention of contrast-induced nephropathy.

INTRODUCTION: For the prevention of contrast-induced nephropathy (CIN) after coronary angiography, hydration by 0.9% sodium chloride solution and N-acetylcysteine is currently recommended. However, it is unclear whether volume supplementation with sodium bicarbonate is better than with sodium chloride when used in conjunction with nonionic, low-osmolar iopamidol. The aim of this study was to analyze and compare the effects of sodium bicarbonate and sodium chloride on renal function in 145 patients exposed to nonionic iso-osmolar contrast medium iodixanol in a randomized study. PATIENTS AND METHODS: Renal Insufficiency Following Radiocontrast Exposure is a prospective, randomized, single-center, double-blinded trial of 145 patients (age 72.6+/-6.7 years) with elevated baseline serum creatinine levels (mean 132.6+/-29.3 micromol/l). Eligible patients were randomized to either a 154 mEq/l infusion of sodium bicarbonate (n=71, group I) or sodium chloride 0.9% solution (n=74, group II). The primary endpoint was serum creatinine elevation beyond 25% or 44 micromol/l on the first or second day following exposure to the contrast medium. Serum creatinine, serum cystatin C, plasma viscosity, urinary enzymes alanine aminopeptidase and N-acetyl-beta-D-glucosaminidase, and alpha1-microglobulin were measured at baseline and on days 1 and 2 after contrast medium administration. RESULTS: An overall proportion of five CIN (3.4%) was observed with equal distribution among the groups (4.2% in sodium bicarbonate group vs. 2.7% in sodium chloride group; P=0.614). Parameters of renal function demonstrated no differences between the two hydration regimens on day 1 after angiography; even on day 2 most parameters were similar in groups I and II. CONCLUSION: Renal Insufficiency Following Radiocontrast Exposure demonstrates a homogeneously low rate of CIN after exposure to nonionic, iso-osmolar iodixanol regardless of the use of either bicarbonate sodium or sodium chloride solution for volume supplementation. Low-toxicity contrast media and any hydration may offset potential antioxidant effects of sodium bicarbonate.

Current role of endovascular therapy in Marfan patients with previous aortic surgery.

The Marfan syndrome is a heritable disorder of the connective tissue which affects the cardiovascular, ocular, and skeletal system. The cardiovascular manifestation with aortic root dilatation, aortic valve regurgitation, and aortic dissection has a prevalence of 60% to 90% and determines the premature death of these patients. Thirty-four percent of the patients with Marfan syndrome will have serious cardiovascular complications requiring surgery in the first 10 years after diagnosis. Before aortic surgery became available, the majority of the patients died by the age of 32 years. Introduction in the aortic surgery techniques caused an increase of the 10 year survival rate up to 97%. The purpose of this article is to give an overview about the feasibility and outcome of stent-graft placement in the descending thoracic aorta in Marfan patients with previous aortic surgery.

[Percutaneous transplantation of autologous myoblasts in ischemic cardiomyopathy]. / Perkutane intramyokardiale Implantation von autologen Myoblasten bei ischämischer Kardiomyopathie.

BACKGROUND AND PURPOSE: Cell transplantation is emerging as a novel approach for the treatment of end-stage cardiac disease. In contrast to most human studies using intramyocardial injection of myoblasts during coronary artery bypass grafting (CABG) or left ventricular assist device implantation, the authors investigated both safety and feasibility of transcatheter transplantation of autologous skeletal myoblast as a standalone procedure in six patients with ischemic heart failure, and compared them to six control patients matched for demographic and clinical characteristics. METHODS AND RESULTS: Skeletal myoblast transplantation by catheter-based injection was technically successful in all six patients with no complications; 19+/-10 injections were performed/patient corresponding to 210 x 10(6)+/-150 x 10(6) cells/patient. Postinterventional Holter monitoring and ICD memory check documented three episodes of ventricular tachycardia in two patients after myoblast implantation, one at 30 days in patient 1, and two at 27 and 41 days in patient 2. Patient 1, although asymptomatic, was subsequently subjected to oral amiodarone since he refused an ICD; in patient 2 each tachycardia was terminated by a previously implanted ICD. Both patients were followed for 6 months without any evidence of repeat ventricular arrhythmia. Matched control patients revealed one episode of ventricular tachycardia in three patients each of which was aborted by ICD discharge within 6 months of observation. None of the documented ventricular tachycardias in both groups occurred in relation to any new myocardial necrosis which was excluded by ECG and cardiac enzymes. Left ventricular ejection fraction (LVEF) rose from 24.3+/-6.7% at baseline to 33.2+/-10.2% 6 months after myoblast implantation (p=0.02 vs. baseline); in matched controls LVEF decreased from 24.7+/-4.6% to 22.2+/-6.2% (p<0.05 vs. myoblasttreated group at 6 months). Moreover, the 6-min walk test revealed an improvement from 371+/-49 m to 493+/-86 m 6 months after implantation (p=0.003 vs. baseline and p=0.015 vs. controls), whereas matched controls were unchanged at 360+/-24 m and 369+/-26 m, respectively. Accordingly, NYHA functional class improved from 3.17+/-0.41 to 1.67+/-0.82 within 6 months of myoblast implantation (p=0.001 vs. baseline and p=0.01 vs. controls), while NYHA class remained unchanged at 3+/-0 in matched controls. CONCLUSION: Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe and promising and, thus, warrants the scrutiny of larger randomized double-blind multi-center trials with longer follow-up surveillance.

Thrombin activatable fibrinolysis inhibitor (TAFI) levels in patients with coronary artery disease investigated by angiography.

Due to its role in the balance between coagulation and fibrinolysis, thrombin activatable fibrinolysis inhibitor (TAFI) may be involved in the development of cardiovascular diseases. We studied 362 patients with coronary artery disease (CAD) and 134 control subjects free of CAD, both groups investigated by angiography. TAFI antigen levels were determined in venous and intracoronary plasma samples and were related to metabolic and hemostatic risk factors and extent of coronary atherosclerosis. Venous TAFI levels tended to be higher in CAD patients compared to controls, whereas this difference was significant in intracoronary samples. A subgroup of patients who had not experienced acute myocardial infarction or undergone previous cardiac interventions showed significantly higher TAFI levels in both venous and intracoronary plasma samples. TAFI levels correlated with acute phase reactants indicating a role for TAFI in inflammation. However, TAFI levels did not correlate with extent of coronary atherosclerosis and among the classical cardiovascular risk factors TAFI levels only correlated with total cholesterol and fibrinogen concentration. Our results suggest that TAFI might be a risk factor for the development of CAD.

Novel femoral artery puncture closure device in patients undergoing interventional and diagnostic cardiac procedures.

BACKGROUND: The wide range of closure devices for arterial access sites still leaves room for improvement. METHODS AND RESULTS: We report our initial experience with a novel, cost-effective, suture-mediated device (6 French X-PRESS device, X-SITE Medical, Blue Bell, Pennsylvania) for closure of the arterial access site after both diagnostic and therapeutic interventions. A total of 51 consecutive patients are reported. The closure was performed immediately after the procedure. No patient had more than 5,000 U heparin administered during the procedure. The closure device was used in 36 patients (73%) after diagnostic angiography and in 15 patients (27%) after therapeutic intervention. The device could be successfully deployed in 48 patients (94%). In the remaining 3 cases (6%), hemostasis was achieved with standard manual compression without any further event. Immediate total hemostasis was achieved with the device in 44 of 48 patients (92%). Four devices (8%) could not be deployed correctly due to technical problems and the patients needed additional manual compression. The average time to achieve complete hemostasis was 5.5 +/- 3.5 minutes (range, 3-26 minutes). The patients were ambulated after a period of 1.3 +/- 0.4 hours of bedrest (range, 0.8-3.5 hours). Time to possible discharge was 4.2 +/- 3.4 hours (range, 0.9-12.5 hours). One patient experienced a minor complication (hematoma < 6 cm) and was treated with manual compression without clinical sequelae. Telephone follow-up was carried out 2 weeks after deployment and revealed no sequelae. CONCLUSION: The 6 French X-PRESS device is safe and effective in providing rapid hemostasis following interventional or diagnostic catheterization procedures. Use of the device is associated with a low rate of complications and facilitates quick hemostasis, mobilization and discharge.

[Interventional closure of persistent foramen ovale in patients after crytogenic stroke]. / Interventioneller Verschluss des persistierenden Foramen ovale nach kryptogenem Insult.

A persistent foramen ovale can be a possible cause of paradoxical cerebral embolism. Thranscatheter closure by transcatheter technique has a high success rate and is a recurrence prevention measure. This paper reviews of patent foramen ovale anatomy, pathophysiology, and clinical impact and discusses current therapeutic options.

Effect of antibiotic treatment in patients with postimplantation syndrome after aortic stent placement.

INTRODUCTION AND OBJECTIVES: Postimplantation syndrome that can develop after stent placement is characterized by fever, leukocytosis and an elevated C-reactive protein level or by coagulation disturbances, or by a combination of these features. It is a transient condition that frequently appears following endovascular treatment. At present, no data are available on the effect of antibiotics on postimplantation syndrome after placement of a thoracic endoprosthesis. METHODS: This prospective single-center study involved 40 patients. Of these, 20 received peri-interventional (for 24 hours) antibiotic treatment with cefuroxime, 20 mg/ kg three times per day, while 20 received prolonged (for 7 days) treatment at the same dosage. Peripheral blood samples were taken before the intervention and 6 h, 12 h, 24 h, 48 h, 3 days, 5 days, and 7 days after. RESULTS: There was no significant difference in clinical or laboratory findings between the two treatment strategies, and subsequent changes in clinical and laboratory parameters over time were similar in the two groups. All parameters returned to baseline values within 7 days. CONCLUSIONS: Prolonging antibiotic treatment beyond the day of endovascular intervention was not observed to provide any short- or long-term clinical benefit in patients with postimplantation syndrome, given that all blood samples were sterile.

[Quadricuspid aortic valve as an unusual cause of severe aortic regurgitation]. / Quadrikuspide Aortenklappe als ungewöhnliche Genese einer ausgeprägten Aortenklappeninsuffizienz.

BACKGROUND: Both, acute and chronic aortic insufficiency, can be caused by various conditions. While the acute form is often associated with an endocarditis, type A aortic dissection and trauma, one possible cause of chronic aortic insufficiency is a congenital malformation of the aortic valve. Among these malformations, the quadricuspid aortic valve is the most rare form. The diagnosis is often made by Doppler echocardiography, during cardiac surgery, or postmortem. CASE REPORT: A 44-year-old female patient presented with a 2-year history of increasing dyspnea on exertion. The physical examination revealed a diastolic heart murmur in the second right intercostal space and a blood pressure of 170/60 mmHg. Transthoracic and transesophageal Doppler echocardiography disclosed a quadricuspid aortic valve with severe aortic insufficiency. After implantation of a mechanical aortic valve, the patient was clinically well. CONCLUSION: Quadricuspid aortic valve, often associated with aortic insufficiency, is a rare condition. The diagnosis can be made by Doppler echocardiography. The special treatment should be based on objective and subjective findings. In the absence of severe aortic regurgitation or clinical signs, a medical treatment with close follow-up is justified. In case of severe aortic regurgitation or clinical signs of cardiac decompensation, surgical treatment is recommended.

Rapid pacing for better placing: comparison of techniques for precise deployment of endografts in the thoracic aorta.

PURPOSE: To investigate the safety, efficacy, impact on positioning, and neurocognitive outcomes of 3 conceptually different methods of avoiding the "windsock" effect during thoracic stent-graft placement. METHODS: A retrospective review was conducted of 70 patients (48 men; mean age 63 years) who underwent elective or emergency stent-graft placement in the thoracic aorta for various pathologies. Twenty-seven patients (18 men; mean age 64+/-12 years) had stent-graft positioning during rapid right ventricular (RV) pacing at 180 to 200 beats per minute. Another 27 patients (18 men; mean age 62+/-12 years) had stent-graft placement under controlled hypotension (

Interventional closure with Amplatzer PFO occluder of patent foramen ovale in patients with paradoxical cerebral embolism.

Percutaneous transcatheter closure has been proposed as an alternative to surgical closure or long-term anticoagulation in patients with presumed paradoxical embolism and patent foramen ovale (PFO). We report our mid-term results of 55 consecutive symptomatic patients (mean age: 47 years, range: 20-79) who underwent percutaneous transcatheter closure of PFO after at least one event of cerebral ischemia; 16 (29%) patients had at least one transient ischemic attack and 39 (71%) patients at least one embolic stroke. Multiple embolic events had occurred in 6 (11%) patients. Percutaneous transcatheter closure was technically successful in all 55 patients (100%). For the majority of patients, an Amplatzer PFO occluder measuring 25 mm in diameter (n=49) or an Amplatzer PFO occluder measuring 35 mm in diameter (n=6) was used. Complete occlusion by color Doppler and transesophageal contrast echocardiography investigation was achieved in 96% at follow-up 3-6 months after implantation; only 2 patients had a trivial residual shunt at follow-up. Mean fluoroscopy time was 6.7 minutes (range: 1.7-47.1), and in-hospital follow-up was uneventful except for 1 patient who developed a cardiac tamponade requiring uneventful and successful needle pericardiocentesis. At a mean follow-up of 19 months (range: 3-32) no recurrent embolic neurological events was observed. Transcatheter closure of PFO with Amplatzer PFO occluder devices is a safe and effective therapy for patients with previous paradoxical embolism and aneurysmatic or nonaneurysmatic PFO. Percutaneous closure is associated with a high success rate, low incidence of hospital complications, and freedom of cerebral ischemia events.

[Extra-cardiac chest pain]. / Der extrakardiale Thoraxschmerz.

In patients with an acute chest pain syndrome the primary requirement is to diagnose or exclude acute myocardial ischemia or myocardial infarction. However, only 30% of patients admitted and evaluated for chest pain ultimately reveal the diagnosis of acute coronary syndrome.Traditionally, the initial evaluation of patients presenting with chest discomfort or pain to an emergency department or any general practice involves the triad of history, physical examination, and ECG and chest film evaluation. With the diagnostic routine of bedside enzymatic tests for cardiac biomarkers, it has become easier to identify acute coronary syndromes, but at the same time more compelling to pinpoint other differential diagnoses, once coronary syndromes are excluded. When a cardiac origin of any non-suggestive chest pain syndrome has been excluded, a broad spectrum of other causes for noncardiac chest pain needs to be evaluated. Potential underlying disorders are listed in this overview and grouped according to pathoanatomic origin into aortic, respiratory, and gastroesophageal disorders, musculoskeletal pathology, and somatization disorders. This article reviews both symptoms and diagnostic pathways in patients with noncardiac chest pain, and eventually offers a rational strategy for an efficacious workup of a wide spectrum of important differential diagnoses.

Transcatheter transplantation of autologous skeletal myoblasts in postinfarction patients with severe left ventricular dysfunction.

PURPOSE: To report a case-controlled safety and feasibility study of transcatheter transplantation of autologous skeletal myoblasts as a stand-alone procedure in patients with ischemic heart failure. METHODS: Six men (mean age 66.2+/-7.2 years) were eligible for transcatheter transplantation of autologous skeletal myoblasts cultured from quadriceps muscle biopsies. Six other men (mean age 65.7+/-6.3 years) were selected as matched controls (no muscle biopsies). A specially designed injection catheter was advanced through a femoral sheath into the left ventricle cavity, where myoblasts in solution (0.2 mL/injection) were injected into the myocardium via a 25-G needle. At baseline and in follow-up, both groups underwent Holter monitoring, a 6-minute walk test, New York Heart Association (NYHA) class determination, and echocardiography with dobutamine challenge. RESULTS: Skeletal myoblast transplantation was technically successful in all 6 patients with no complications; 19+/-10 injections were performed per patient (210 x 10(6)+/-150 x 10(6) cells implanted per patient). Left ventricular ejection fraction (LVEF) rose from 24.3%+/-6.7% at baseline to 32.2%+/-10.2% at 12 months after myoblast implantation (p=0.02 versus baseline and p<0.05 versus controls); in matched controls, LVEF decreased from 24.7%+/-4.6% to 21.0%+/-4.0% (p=NS). Walking distance and NYHA functional class were significantly improved at 1 year (p=0.02 and p=0.001 versus baseline, respectively), whereas matched controls were unchanged. CONCLUSIONS: Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe, and promising. Scrutiny with randomized, double-blinded, multicenter trials appears warranted.

Four French catheters for diagnostic coronary angiography.

A randomized study was conducted to assess the feasibility of 4 Fr catheters for diagnostic coronary angiograms. A total of 1,114 consecutive patients were randomized to 4 or 5 Fr catheters. Ease of use of catheters was subjectively assessed by the primary operator and the picture quality was assessed by two independent observers with a good interobserver variability (r = 0.94; P < 0.001). Predischarge local complications were recorded by the attending physician. No statistically significant difference was observed in the picture quality for the left coronary artery, right coronary artery, aorta, left ventricle, venous grafts, or renal arteries between the two groups. Fluoroscopy time (7.1 +/- 5.6 for 4 Fr vs. 6.7 +/- 5.7 min for 5 Fr) and contrast quantity (140 +/- 58 vs. 144 +/- 57 ml) were comparable between the two groups. There was a statistically significant difference in favor of the 5 Fr group as regards maneuverability of catheters (93% vs. 79%; P < 0.001), and 5 Fr pigtail catheters crossed the aortic valve easier than the 4 Fr pigtail catheters (91% vs. 81%; P < 0.001). Crossover to the other catheter size or a larger sheath was more frequent with 4 Fr catheters (33/522 vs. 3/592; P < 0.001). Median time to hemostasis was 9 min for 4 Fr and 14 min for 5 Fr (P < 0.001). Of the 4 Fr patients, 84% could be mobilized at 1 hr and 86% of 5 Fr patients at 2 hr. Significant hematomas were observed in 2% with 4 Fr or 5 Fr and small hematomas in 10% and 16%, respectively (P = NS). Time to discharge was comparable in both groups (4.0 +/- 3.2 with 4 Fr vs. 4.3 +/- 3.7 hr with 5 Fr). The 4 Fr catheters are a good alternative for diagnostic coronary angiograms. The increased difficulty in maneuverability and a need for catheter changes in 70% are compensated for in part by easier hemostasis. With increasing use and finesse of these catheters, the difficulty in maneuverability are likely to be overcome.

Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance.

PURPOSE: To examine the clinical consequences and/or potential need for postinterventional transposition after stent-graft occlusion of the left subclavian artery (LSA). METHODS: The records of 171 consecutive patients (128 men; mean age 60.2+/-13.2 years, range 20-83) undergoing elective stent-graft repair in the thoracic aorta were reviewed to identify intentional endograft coverage of the ostial LSA, as documented by transesophageal echocardiography and/or aortography. Patients were treated for subacute type B dissection, true aneurysm, pseudoaneurysm, or previously operated type A dissection with persistent false lumen flow in the descending aorta. Among the 171 cases, 22 (12.9%) patients were identified with stent-graft occlusion of the LSA. RESULTS: A systolic blood pressure differential existed between the right (138.4+/-14.0 mmHg) and the left (101.8+/-21.0 mmHg; p<0.05) arms after occlusion of the LSA. No patient showed a malperfusion syndrome during postinterventional hospitalization. During a mean follow-up of 24.0+/-15.8 months, 15 (68.2%) patients remained completely asymptomatic, with no functional deficit or temperature differential between the arms, while 7 patients reported mild symptoms of a subclavian steal syndrome. However, no patient required any secondary surgical intervention. CONCLUSIONS: Stent-graft-induced occlusion of the ostial LSA was tolerated by all patients without chronic functional deficit. In the absence of stenotic vertebral and/or carotid arteries and with a documented intact vertebrobasilar system, prophylactic transposition of the LSA is not required prior to intentional stent-graft occlusion of the LSA.