Effective Distance between Aortic Valve and Conduction System Is an Independent Predictor of Persistent Left Bundle Branch Block during Transcatheter Aortic Valve Implantation.

Background and objectives: Persistent left bundle branch block (P-LBBB) has been associated with poor clinical outcomes of transcatheter aortic valve implantation (TAVI) procedures. We hypothesized that the distance from the aortic valve to the proximal conduction system, expressed as the effective distance between the aortic valve and conduction system (EDACS), can predict the occurrence of P-LBBB in patients undergoing a TAVI procedure. Materials and methods: In a retrospective study, data from 269 patients were analyzed. EDACS was determined using two longitudinal CT sections. Results: Sixty-four of the patients developed P-LBBB. EDACS ranged between -3 and +18 mm. EDACS was significantly smaller in P-LBBB than in non-P-LBBB patients (4.6 (2.2-7.1) vs. 8.0 (5.8-10.2) mm, median values (interquartile range); p < 0.05). Receiver operating characteristic analysis showed an area under the curve of 0.78 for predicting P-LBBB based on EDACS. In patients with EDACS of ≤3 mm and >10 mm, the chance of developing P-LBBB was ≥50% and <10%, respectively. Conclusions: A small EDACS increases the risk for the development of P-LBBB during TAVI by a factor of >25. As EDACS can be measured pre-procedurally, it may be a valuable additional factor to weigh the risks of transcatheter and surgical aortic valve replacement.

Occurrence and Persistency of Conduction Disturbances during Transcatheter Aortic Valve Implantation.

Background and Objectives: Conduction disturbances such as left bundle branch block (LBBB) and complete atrio-ventricular block (cAVB) are relatively frequent complications following trans-catheter aortic valve implantation (TAVI). We investigated the dynamics of these conduction blocks to further understand luxating factors and predictors for their persistency. Materials and Methods: We prospectively included 157 consecutive patients who underwent a TAVI procedure. Electrocardiograms (ECGs) were obtained at specific time points during the TAVI procedure and at follow-up until at least six months post-procedure. Results: Of the 106 patients with a narrow QRS complex (nQRS) before TAVI, ~70% developed LBBB; 28 (26.4%) being classified as super-transient (ST-LBBB), 20 (18.9%) as transient (T-LBBB) and 24 (22.6%) as persistent (P-LBBB). Risk of LBBB was higher for self-expandable (SE) than for balloon-expandable (BE) prostheses and increased with larger implant depth. During the TAVI procedure conduction disturbances showed a dynamic behavior, as illustrated by alternating kinds of blocks in 18 cases. Most LBBBs developed during balloon aortic valvuloplasty (BAV) and at positioning and deployment of the TAVI prosthesis. The incidence of LBBB was not significantly different between patients who did and did not undergo BAV prior to TAVI implantation (65.3% and 74.2%, respectively (p = 0.494)). Progression to cAVB was most frequent for patients with preexisting conduction abnormalities (5/34) patients) and in patients showing ST-LBBB (6/28). Conclusions: During the TAVI procedure, conduction disturbances showed a dynamic behavior with alternating types of block in 18 cases. After a dynamic period of often alternating types of block, most BBBs are reversible while one third persist. Patients with ST-LBBB are most prone to progressing into cAVB. The observation that the incidence of developing LBBB after TAVI is similar with and without BAV suggests that a subgroup of patients has a substrate to develop LBBB regardless of the procedure.

Reservations about the Selvester QRS score in left bundle branch block - Experience in patients with transcatheter aortic valve implantation.

BACKGROUND: The Selvester QRS score (S-score) estimates myocardial scar using electrocardiographic criteria. We evaluated the S-score for left bundle branch block (LBBB). MATERIAL AND METHODS: Studied were 36 patients who developed persistent LBBB upon transcatheter aortic valve implantation (TAVI, TAVI-LBBB group) and 36 matched patients with persistent narrow QRS (TAVI-nQRS group). Electrocardiograms were recorded before and briefly after TAVI and during ~6months follow-up. S-score was calculated using criteria for hypertrophic (in absence of LBBB) or LBBB hearts. RESULTS: In TAVI-LBBB patients correlation between S-scores pre-TAVI and post-TAVI was absent (R2=0.023). High S-scores post-TAVI occurred in patients with low pre-TAVI scores. Pre-post TAVI scores correlated weakly in TAVI-nQRS (R2=0.182), indicating a possible influence of ventricular unloading by TAVI. In both groups S-scores at post-TAVI and follow-up compared reasonably (R2=0.389 and R2=0.386), indicating reproducibility in more stable conditions. CONCLUSION: This study indicates that the use of the LBBB S-score criteria overestimates scar size and that caution is recommended in the use of the score in patients with LBBB.

Low contrast media volume in pre-TAVI CT examinations.

PURPOSE: To evaluate image quality using reduced contrast media (CM) volume in pre-TAVI assessment. METHODS: Forty-seven consecutive patients referred for pre-TAVI examination were evaluated. Patients were divided into two groups: group 1 BMI < 28 kg/m(2) (n = 29); and group 2 BMI > 28 kg/m(2) (n = 18). Patients received a combined scan protocol: retrospective ECG-gated helical CTA of the aortic root (80kVp) followed by a high-pitch spiral CTA (group 1: 70 kV; group 2: 80 kVp) from aortic arch to femoral arteries. All patients received one bolus of CM (300 mgI/ml): group 1: volume = 40 ml; flow rate = 3 ml/s, group 2: volume = 53 ml; flow rate = 4 ml/s. Attenuation values (HU) and contrast-to-noise ratio (CNR) were measured at the levels of the aortic root (helical) and peripheral arteries (high-pitch). Diagnostic image quality was considered sufficient at attenuation values > 250HU and CNR > 10. RESULTS: Diagnostic image quality for TAVI measurements was obtained in 46 patients. Mean attenuation values and CNR (HU ± SD) at the aortic root (helical) were: group 1: 381 ± 65HU and 13 ± 8; group 2: 442 ± 68HU and 10 ± 5. At the peripheral arteries (high-pitch), mean values were: group 1: 430 ± 117HU and 11 ± 6; group 2: 389 ± 102HU and 13 ± 6. CONCLUSION: CM volume can be substantially reduced using low kVp protocols, while maintaining sufficient image quality for the evaluation of aortic root and peripheral access sites. KEY POINTS: • Image quality could be maintained using low kVp scan protocols. • Low kVp protocols reduce contrast media volume by 34-67 %. • Less contrast media volume lowers the risk of contrast-induced nephropathy.

MDCT evaluation of aortic root and aortic valve prior to TAVI. What is the optimal imaging time point in the cardiac cycle?

OBJECTIVES: To determine the optimal imaging time point for transcatheter aortic valve implantation (TAVI) therapy planning by comprehensive evaluation of the aortic root. METHODS: Multidetector-row CT (MDCT) examination with retrospective ECG gating was retrospectively performed in 64 consecutive patients referred for pre-TAVI assessment. Eighteen different parameters of the aortic root were evaluated at 11 different time points in the cardiac cycle. Time points at which maximal (or minimal) sizes were determined, and dimension differences to other time points were evaluated. Theoretical prosthesis sizing based on different measurements was compared. RESULTS: Largest dimensions were found between 10 and 20% of the cardiac cycle for annular short diameter (10%); mean diameter (10%); effective diameter and circumference-derived diameter (20%); distance from the annulus to right coronary artery ostium (10%); aortic root at the left coronary artery level (20%); aortic root at the widest portion of coronary sinuses (20%); and right leaflet length (20%). Prosthesis size selection differed depending on the chosen measurements in 25-75% of cases. CONCLUSION: Significant changes in anatomical structures of the aortic root during the cardiac cycle are crucial for TAVI planning. Imaging in systole is mandatory to obtain maximal dimensions. KEY POINTS: • Most aortic root structures undergo significant dimensional changes throughout the cardiac cycle. • The largest dimensions of aortic parameters should be determined to optimize TAVI. • Circumference-derived diameter showed maximum dimension at 20% of the cardiac cycle.

Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear. METHODS AND RESULTS: Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174-834) days in patients with and 450 (interquartile range, 253-725) days in patients without LBBB (P=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (P=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12-2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15-2.10), female sex (HR, 1.39; CI, 1.04-1.85), left ventricular ejection fraction ≤50% (HR, 1.38; CI, 1.02-1.86), and baseline creatinine (HR, 1.32; CI, 1.19-1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively; P<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB. CONCLUSIONS: All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.

Occupational radiation dose during transcatheter aortic valve implantation.

OBJECTIVES: To examine the occupational radiation dose during transcatheter aortic valve implantation (TAVI) in both transfemoral and transapical approach. BACKGROUND: Interventional fluoroscopic guided cardiac procedures lead inevitably to radiation exposure of workers, which over time may be associated with an increased incidence of cancer and cataract. METHODS: Using thermoluminescence dosimeters, the radiation dose of the cardiothoracic surgeon, cardiologist, and two assistants was measured on the apron at chest height and on both feet. In addition, dose measurements were performed on the hands of the two operators and on the eyes of the cardiothoracic surgeon. This study involved 11 transapical and 11 transfemoral TAVIs. The effective dose was estimated from the dose measured on the apron. RESULTS: In the transapical TAVI the cardiothoracic surgeon received a significantly higher equivalent hand dose (average ± SD), 1.9 ± 0.6 mSv, equivalent foot dose, 0.57 ± 0.31 mSv, equivalent eye dose, 0.11 ± 0.06 mSv, and effective dose, 0.03 ± 0.02 mSv, than any staff member in the transfemoral TAVI, with highest average doses of 0.03 ± 0.02 mSv, 0.22 ± 0.19 mSv, 0.03 ± 0.01 mSv, and 0.003 ± 0.005 mSv, respectively. CONCLUSIONS: This study provides hitherto unavailable data on the radiation exposure of staff during transfemoral and transapical TAVIs. Relatively high doses were observed in the transapical approach. The dose of the right hand of the cardiothoracic surgeon will reach the annual limit within about 250 procedures per year, implying that hand dose measurements should become standard and that the number of procedures performed by the cardiothoracic surgeon involving X-rays may have to be limited.

Emergency transthoracic transapical mitral valve-in-valve implantation.

OBJECTIVES: The valve-in-valve (VIV) technique is an emerging therapeutic option for patients with failure of previously implanted xenografts. We describe a balloon-expandable transthoracic transapical mitral VIV implantation in an emergency setting in a 69-year-old woman with dysfunction of the mitral bioprosthesis. METHODS: Left ventricular apical access was applied. After balloon valvuloplasty, a 26-mm Edwards-Sapien transcatheter valve (Edwards Lifesciences LLC, Irvine, CA, USA) was deployed within the mitral xenograft, using rapid ventricular pacing. RESULTS: The transcatheter valve functioned properly postoperatively and three-dimensional echocardiography carried out 1 month later showed a well-functioning VIV prosthesis and no mitral stenosis (mitral valve area 3 cm(2) , mean gradient 3 mmHg). CONCLUSIONS: In this patient, VIV implantation was found to be a safe alternative to an emergent valve replacement. It might represent a suitable option to conventional procedures even among lower risk patients.

Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update.

BACKGROUND: Despite tremendous improvement in molecular properties over the last century, intravascular injection of iodinated contrast material may still have systemic and hemodynamic consequences. Patients with pre-existing renal insufficiency may be at risk for acute kidney injury, which may be associated with an increased risk of the need for dialysis and mortality in the long term. Many questions as to the physiological pathways, optimal definition, and incidence of contrast-induced acute kidney injury remain open. These uncertainties are reflected in the changing landscape of this field in terms of nomenclature, research, and clinical practice. METHODS: Clinical practice guidelines for the prevention of post-contrast acute kidney injury all recommend giving prophylaxis in the form of intravenous hydration to high-risk patients. Solid evidence for this strategy is lacking. This article gives an overview of the changing landscape of post-contrast acute kidney injury and prophylactic intravenous hydration, with the aim of supporting informed decision-making in clinical practice. RESULTS: Recent data have caused a shift in guideline recommendations: 90 % of patients formerly considered high-risk for contrast-induced acute kidney injury no longer qualify for prophylaxis. The remaining high-risk patients, with severe chronic kidney disease, represent a vulnerable population for whom intravenous hydration may provide some benefits but also carries risk. CONCLUSION: Intravenous hydration may benefit 'new' high-risk patients. However, it also confers risk. A dual approach to screening patients will help avoid this risk in clinical practice. KEY POINTS: · Intravenous hydration is the cornerstone for preventing contrast-induced acute kidney injury. · Solid evidence is lacking; recent data caused a shift in guideline recommendations. · Intravenous hydration may benefit 'new' high-risk patients with severe chronic kidney disease; however, it also confers risk. · A dual approach to screening patients will help avoid this risk in clinical practice. CITATION FORMAT: · Nijssen E, Rennenberg R, Nelemans P et al. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. Fortschr Röntgenstr 2021; 193: 151 - 159.

Prophylaxis in High-Risk Patients With eGFR < 30 mL/min/1.73 m2: Get the Balance Right.

OBJECTIVES: Clinical guidelines recommend prophylactic intravenous fluids for patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m to prevent adverse postcontrast outcomes. These patients represent a small minority of the population receiving intravascular iodinated contrast material, and data are not readily available. The current study aim is to gain insight into positive and negative effects of prophylaxis by comparing postcontrast outcomes in high-risk patients who did and did not receive prophylaxis. MATERIALS AND METHODS: Observational data were gathered over 4 years. Inclusion criteria were age 18 years or older, eGFR less than 30 mL/min/1.73 m, and elective intravascular iodinated contrast administration. Exclusion criteria were dialysis and nonstandard periprocedural prophylaxis. Primary outcome was postcontrast acute kidney injury (>25% or >44 µmol/L serum creatinine increase within 2-5 days). Secondary outcomes were change in eGFR, 5 mL/min/1.73 m or greater eGFR decline, dialysis, and mortality at 1 month postcontrast including primary cause, as well as complications of prophylaxis. Results were stratified by contrast procedure type and corrected for potential confounders. RESULTS: Of all 55,474 elective procedures with intravascular contrast administration, 362 patients met the inclusion criteria: 281 (78%) received standard 0.9% NaCl prophylaxis and 81 (22%) received no prophylaxis. Prophylaxis versus no prophylaxis adjusted odds ratios were nonsignificant and less than 1 for postcontrast renal outcomes (postcontrast acute kidney injury, eGFR decline, dialysis), indicating a trend toward a protective effect of prophylaxis. For mortality, adjusted odds ratios were nonsignificant and greater than 1, indicating a trend toward higher mortality risk after prophylaxis. Of the primary causes of death analyzed in prophylaxis patients, 24% (5/21) were related to prophylaxis. Among 281 prophylaxis patients, 18 (6.4%) complications of prophylaxis occurred: 15 heart failures and 3 arrhythmias. CONCLUSIONS: Based on this study, no standard recommendation with regard to giving or withholding prophylaxis can be given. Prophylactic fluids may confer some protection against postcontrast renal adverse events but may also contribute toward increased risk of short-term death. In this setting, benefits and risks of prophylaxis must be carefully weighed and cardiac parameters assessed for each individual patient.

Evaluation of Safety Guidelines on the Use of Iodinated Contrast Material: Conundrum Continued.

OBJECTIVES: Recently, safety guidelines for the use of intravascular iodinated contrast material have been updated, and the recommended threshold for giving prophylaxis to prevent contrast-induced nephropathy (CIN) has been reduced to estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m. Data on this population in the context of CIN, especially evidence for efficacy of the recommendation of prophylactic intravenous hydration, are lacking. The aim of the current study was to test implicit assumptions underlying the guideline update: (1) patients with eGFR <30 mL/min/1.73 m, as opposed to former high-risk patients with eGFR ≥30 mL/min/1.73 m, are at high risk of CIN and other unfavorable outcomes after intravascular iodinated contrast material administration; (2) prophylactic intravenous hydration mitigates this risk; and (3) the risk of administering prophylactic intravenous hydration does not outweigh the positive preventive effect. MATERIALS AND METHODS: Retrospectively, data were collected from all patients with eGFR <30 mL/min/1.73 m referred for an elective procedure with intravascular iodinated contrast material administration and excluded from the AMACING trial (A MAastricht Contrast-Induced Nephropathy Guideline trial). We compared these patients with those prospectively included in the AMACING trial (with eGFR 30-59 mL/min/1.73 m and risk factors). Main outcomes were CIN (defined as an increase in serum creatinine by more than 25% or 44 µmol/L within 2-6 days postcontrast exposure), dialysis and mortality within 35 days postcontrast exposure, and complications of prophylactic intravenous hydration. RESULTS: A total of 28,803 patients referred for an elective procedure with intravascular iodinated contrast administration were prospectively screened for inclusion in the AMACING trial. One hundred fifty-seven (0.5%) patients had eGFR <30 mL/min/1.73 m, and 155 received intravascular iodinated contrast material. Standard prophylaxis was given to 119/155 of these patients. Data on 2- to 6-day serum creatinine, 35-day dialysis 35-day mortality, and complications of prophylactic intravenous hydration were available for 59/119 (50%), 118/119 (99%), 119/119 (100%), and 119/119 (100%) standard prophylaxis patients, respectively. Incidences in eGFR <30 mL/min/1.73 m versus AMACING patients are as follows: CIN 13.6% versus 2.7% (P = 0.0019); 35-day dialysis 0.9% versus 0.0% (P = 0.2646); 35-day mortality 9.2% versus 0.0% (P < 0.0001); complications of prophylactic intravenous hydration 5.9% versus 5.5% (P = 0.8529). CONCLUSIONS: Postcontrast incidences of CIN and mortality at 35 days are significantly higher in the population with eGFR <30 mL/min/1.73 m than in the former high-risk population with eGFR 30 to 59 mL/min/1.73 m, even after prophylactic intravenous hydration. The risk of complications of prophylactic intravenous hydration is similar and substantial in both populations. Obtaining evidence from a randomized trial that efficacy of prophylactic intravenous hydration outweighs the risk of complications is important but may not be feasible.

Prophylactic Intravenous Hydration to Protect Renal Function From Intravascular Iodinated Contrast Material (AMACING): Long-term Results of a Prospective, Randomised, Controlled Trial.

BACKGROUND: The aim of A MAastricht Contrast-Induced Nephropathy Guideline (AMACING) trial was to evaluate non-inferiority of no prophylaxis compared to guideline-recommended prophylaxis in preventing contrast induced nephropathy (CIN), and to explore the effect on long-term post-contrast adverse outcomes. The current paper presents the long-term results. METHODS: AMACING is a single-centre, randomised, parallel-group, open-label, phase 3, non-inferiority trial in patients with estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m2 combined with risk factors, undergoing elective procedures requiring intravenous or intra-arterial iodinated contrast material. Exclusion criteria were eGFR < 30 mL/min/1.73 m2, dialysis, no referral for prophylaxis. The outcomes dialysis, mortality, and change in renal function at 1 year post-contrast were secondary outcomes of the trial. Subgroup analyses were performed based on pre-defined stratification risk factors. AMACING is registered with ClinicalTrials.gov: NCT02106234. FINDINGS: From 28,803 referrals, 1120 at-risk patients were identified. 660 consecutive patients agreed to participate and were randomly assigned (1:1) to no prophylaxis (n = 332) or standard prophylactic intravenous hydration (n = 328). Dialysis and mortality data were available for all patients. At 365 days post-contrast dialysis was recorded in two no prophylaxis (2/332, 0.60%), and two prophylaxis patients (2/328, 0.61%; p = 0.9909); mortality was recorded for 36/332 (10.84%) no prophylaxis, and 32/328 (9.76%) prophylaxis patients (p = 0.6490). The hazard ratio was 1.118 (no prophylaxis vs prophylaxis) for one-year risk of death (95% CI: 0.695 to 1.801, p = 0.6449). The differences in long-term changes in serum creatinine were small between groups, and gave no indication of a disadvantage for the no-prophylaxis group. INTERPRETATION: Assuming optimal contrast administration, not giving prophylaxis to elective patients with eGFR 30-59 mL/min/1.73 m2 is safe, even in the long-term. FUNDING: Stichting de Weijerhorst.

Elective high-risk percutaneous coronary interventions supported by extracorporeal life support.

This study investigated the feasibility of high-risk percutaneous coronary intervention (PCI) in hemodynamically unstable patients supported by modified cardiopulmonary bypass (extracorporeal life support [ELS]). Over a 38-month period, 15 patients (10 men, 5 women, mean age 72 +/- 9 years, mean ejection fraction 34 +/- 15%, angina pectoris New York Heart Association class III to IV) who were not eligible for coronary artery bypass grafting because of high co-morbidity underwent elective high-risk PCI supported by ELS. All lesions were technically challenging. ELS perfusion cannulas in the femoral artery and vein were surgically inserted and removed. Procedural success was achieved in 14 of 15 patients. After a mean perfusion duration of 88 +/- 37 minutes, all patients were weaned from the ELS in the catheterization laboratory. The patients were ventilated for 5.1 +/- 3.3 hours. Blood transfusion was given to 8 patients. Apart from 2 groin bleedings, no other complications occurred. Patients left our hospital after 3.2 +/- 2.8 days. Of the 4 patients who died during the 15 +/- 12-month follow-up, 1 died of a noncardiac cause. In conclusion, in highly selected patients ineligible for bypass surgery, ELS-supported PCI can be performed with promising short- and long-term clinical outcomes. This complex procedure is a safe alternative whenever other options for revascularization are exhausted.

Severely Thrombosed Transcatheter Aortic Valve 9 Months After Implantation.

Bioprosthetic aortic valve thrombosis is a rare complication after transcatheter aortic valve implantation; however, one with a high mortality. We describe the case of a patient with a completely thrombosed transcatheter aortic valve prosthesis 9 months after implantation and review the diagnosis and management of this complication.

Miniature intracardiac assist device provides more effective cardiac unloading and circulatory support during severe left heart failure than intraaortic balloon pumping.

BACKGROUND: Hemodynamic assistance with a miniature intracardiac pump may fill the treatment gap between use of an intraaortic balloon pump (IABP) and the current, more invasive ventricular assist devices. The objective of this study was to compare the hemodynamic efficacy of a miniature intracardiac pump device with that of IABP. METHODS AND RESULTS: Reversible acute mitral regurgitation (AMR) was induced in eight calves by stenting the mitral valve using a vena cava filter. Full and partial AMR assist were compared with maximum IABP support in each animal. In full-support mode, both assist systems increased cardiac output (miniature intracardiac pump, 13% [p < 0.05]; IABP, 3% [p < 0.05]), mean aortic pressure (miniature intracardiac pump, 13% [p < 0.05]; IABP, 8% [p < 0.05]), carotid artery flow (miniature intracardiac pump, 29% [p < 0.05]; IABP, 5% [difference not significant]), and coronary blood flow (miniature intracardiac pump, 25% [difference not significant]; IABP, 34% [p < 0.05]). Again in full-support mode, both systems reduced left atrial pressure (miniature intracardiac pump, 2.4 mm Hg [p < 0.05]; IABP, 0.7 mm Hg [p < 0.05]), peak left ventricular (LV) pressure (miniature intracardiac pump, 13% [p < 0.05]; IABP, 5% [p < 0.05]), and external LV work (miniature intracardiac pump, 29% [p < 0.05]; IABP, 3% [p < 0.05]). Only full miniature intracardiac pump support reduced both end-diastolic LV volume (7%; p < 0.05) and end-systolic LV volume (10%; p < 0.05). IABP mainly improved coronary perfusion, while the miniature intracardiac pump proved more capable of genuinely unloading the LV. CONCLUSIONS: We conclude that during severe acute LV failure, the miniature intracardiac pump is capable of more effective cardiac unloading and circulatory support than IABP.

Efficacy of a new intraaortic propeller pump vs the intraaortic balloon pump: an animal study.

OBJECTIVE: To compare the efficacy of a new intraaortic propeller pump (PP) to provide hemodynamic support to the intraaortic balloon pump (IABP) in an acute mitral regurgitation (MR) animal model. BACKGROUND: A new intraaortic PP (Reitan catheter pump; Jomed; Helsingborg, Sweden) recently has been introduced. The pump's aim is a reduction in afterload via a deployable propeller that is placed in the high descending aorta and can be set at rotational speeds of

Clinical pacing post-conditioning during revascularization after AMI.

Intermittent dyssynchrony, induced by ventricular pacing, during early reperfusion reduces infarct size in pre-clinical studies. We evaluated cardioprotection by pacing post-conditioning (PPC) in ST-segment elevation myocardial infarction in a randomized, controlled, single-center, single-blinded, first-in-man study. Patients with first ST-segment elevation myocardial infarction received either PPC plus percutaneous coronary intervention (PCI) (n = 30) or PCI (n = 30). PPC consisted of 10 episodes of 30-s right ventricular pacing. Infarct size was measured as the area under the curve of creatine kinase (CK) (primary endpoint) and by contrast-enhanced cardiac magnetic resonance. The CK area under the curve was not significantly different between study groups. Adjusted contrast-enhanced cardiac magnetic resonance data showed ∼25% smaller infarct size in PPC + PCI than in PCI patients after 4 days (p = 0.01), 4 months (p = 0.02), and 1 year of PCI (p = 0.08). In PPC + PCI, (uncomplicated) ventricular fibrillation (n = 3) and paroxysmal atrial fibrillation (n = 4) were observed as opposed to 1 and 0 cases in PCI, respectively. We conclude PPC is feasible and may induce cardioprotection during PCI treatment of ST-segment elevation myocardial infarction, but technical improvements are needed to improve safety. (PROTECT: Pacing to Protect Heart for Damage From Blocked Heart Vessel and From Re-opening Blocked Vessel[s]; NCT00409604).