New suture probe canaloplasty combined with suprachoroidal collagen implantation.

PURPOSE: To present the modified surgery technique of new suture probe canaloplasty with a specially prepared monofilament 4.0 polypropylene suture combined with suprachoroidal drainage (ScD) and collagen sheet implantation for non-penetrating glaucoma surgery. METHODS: Prospective study with a twelve months follow-up. A standard 4/0 polypropylene suture (ProleneTM by Ethicon; thickness: approximately 250 m) is cut and shaped with an ophthalmic knife (MANI® Crescent Knife, Mani Inc 8-3 Kiyohara Industrial Park, Utsunomiya, Tochigi 321-3231, Japan) to create a blunt end without sharp or compressed edges. This improves suture probe canaloplasty by providing a more stable and smoother probing device. Schlemm's canal is prepared using the standard technique of canaloplasty with suprachoroidal drainage. Then, instead of using the canaloplasty microcatheter or the previously published 6/0 double-helix suture, Schlemm's canal is probed with the blunt ending of the 4/0 Prolene suture. After successful 360-degree probing, a doubled 10/0 polypropylene tension suture is threaded through the tip of the 4/0 suture. The 4/0 suture is then pulled back and the 10/0 tension sutures are tied at both ends to tension Schlemm's canal. A special collagen sheet (Ologen®) is placed in suprachoroidal space, and the scleral flap is firmly sewed. RESULTS: 115 eyes were included in this prospective study. In 113 cases the Schlemm's canal could completely be probed with the suture probe and canaloplasty with ScD and collagen sheet implantation succeeded. In two cases the intervention was transformed to 360-degree suture trabeculotomy due to an intraoperative cheese-wiring. Twelve months after successful new suture probe canaloplasty with ScD and Collagen Implantation the IOP had decreased by 37.1% (from 21.6 ± 6.0 mmHg with 3.3 different IOP lowering eye drops to 13.5 ± 3.5 mmHg with 1.0 eye drops). 16 Patients did not achieve sufficient IOP levels and underwent 360-degree suture trabeculotomy during the follow-up. One patient had to be treated with further glaucoma surgery to achieve a sufficient IOP level. Complications were hyphema, postoperative IOP elevation and transient hypotony. No serious or sight-threatening complications occurred. CONCLUSION: New suture probe canaloplasty with ScD and collagen sheet implantation yields the opportunity to conduct a cost-effective canaloplasty easier and less complicated than with the previously described method with the twisted 6/0 suture. The safety profile and IOP lowering effect is comparable. In cases where complete probing fails, there is still the opportunity to switch to suture trabeculotomy over the majorly probed part of Schlemm's canal. The pressure lowering effect of the deep sclerectomy with ScD and suprachoroidal collagen sheet implant seems to have an additional impact on the sufficient pressure lowering procedure.

Echocardiographic analysis of acute effects of percutaneous mitral annuloplasty on severity of secondary mitral regurgitation.

AIMS: Percutaneous mitral annuloplasty (PMA) represents a new treatment option for secondary mitral regurgitation (SMR) being associated with higher morbidity and mortality. The present study was aimed to evaluate whether or not acute effects on SMR severity can quantitatively be assessed after PMA. METHODS AND RESULTS: PMA was performed in 30 patients (mean age 76 ± 9; 37% males) with moderate (n = 14) or severe (n = 16) SMR. Vena contracta (VC), left ventricular (LV) velocity-time-integral ratio (VTIMV/LVOT ), effective regurgitant orifice area (EROA) by two-dimensional proximal isovelocity surface area (PISA), regurgitant volume (RVolPISA ) and regurgitant fraction (RFPISA ) by PISA, RVolvolume and RFvolume by LV volume analyses, and parameters describing LV morphology, function, and cardiac performance were assessed by transthoracic echocardiography prior to and after PMA. According to RFPISA /RFvolume , 14 patients showed mild, 15 moderate, and 1 severe SMR after PMA. Mean RF, RVol, EROA, VC, and VTIMV/LVOT were lower directly after PMA (RFPISA : 49% ± 11 vs. 34% ± 13, P < 0.001; RFvolume : 46% ± 10 vs. 34% ± 13, P < 0.001; RVolPISA : 33 mL ± 13 vs. 25 mL ± 12, P < 0.001; RVolvolume : 28 mL ± 17 vs. 20 mL ± 14, P < 0.05; EROAPISA : 0.24 cm2  ± 0.1 vs. 0.19 cm2  ± 0.1, P < 0.05; VC: 5.2 ± 0.1 vs. 4.1 ± 0.2, P < 0.001; VTIMV/LVOT : 1.9 ± 0.4 vs. 1.6 ± 0.5, P < 0.05). Parameters of LV morphology, function, and cardiac performance did not change directly after PMA. CONCLUSIONS: PMA leads to a reduction of MR severity in >80% of SMR patients. Acute effects of PMA can quantitatively be assessed by transthoracic echocardiography.

Regional Disparities of Left Atrial Appendage Wall Contraction in Patients With Sinus Rhythm and Atrial Fibrillation.

BACKGROUND: Patients with atrial fibrillation (AF) exhibit impaired left atrial appendage (LAA) function. However, regional characteristics of LAA function in patients with AF are not defined. METHODS: Consecutive patients (n = 1,195) undergoing transesophageal echocardiography at a university hospital were included. Patients were divided into three groups on the basis of their rhythm: sinus rhythm (SR), paroxysmal AF, and permanent or persistent AF. Regional LAA wall velocities were determined using color Doppler tissue imaging, placing regions of interest at the lateral and medial wall of the LAA. RESULTS: Of the 1,182 patients ultimately included, 691 (59%) were in SR, 371 (32%) had permanent or persistent AF, and 120 (10%) had paroxysmal AF with SR at the time of transesophageal echocardiography. Both lateral and medial LAA wall velocities were lower in patients with AF in comparison with those in SR. Nearly 90% of patients in both groups of patients with AF exhibited a pattern of medial LAA wall velocity greater than lateral LAA wall velocity, in comparison with 20% of patients with SR. The odds ratio for the association of this LAA contraction pattern with AF was 22.14 (95% CI, 12.06-40.64; P < .001). The movement of lateral LAA wall velocity showed the highest correlation with LAA emptying velocity compared with the medial LAA wall (r = 0.67, P < .001). CONCLUSIONS: Lateral LAA wall velocity is higher than medial LAA wall velocity in patients in SR, which reverses in patients with AF. Assessment of LAA regional wall velocity using Doppler tissue imaging appears to be a promising approach to identify patients with paroxysmal AF.