[Mechanical circulatory support systems : When and how much protection does a PCI need?] / Mechanische Kreislaufunterstützungssysteme : Wie viel Schutz braucht eine PCI wann?

The interventional treatment of high-risk patients remains challenging and has a high potential for improvement despite all technical innovations. Mechanical circulatory support (MCS) systems can be meaningful depending on the clinical situation, although a clear study situation for this is so far lacking. Multivessel coronary disease and a high SYNTAX score combined with impaired ventricular function is a possible predictor combination for the use of MCS that justifies the higher risk of complications.

[Imaging in structural heart disease : Impact on interventional therapy]. / Bildgebung bei struktureller Herzerkrankung : Bedeutung für die interventionelle Therapie.

For the treatment of structural heart disease, current options in the catheterization laboratory include MitraClip® implantation for treating severe mitral regurgitation, transcatheter aortic valve implantation (TAVI), closure of a patent foramen ovale (PFO) and occlusion of the left atrial appendage (LAA). These treatment options are based on a precise diagnosis provided by modern cardiac imaging, which is indispensable for treatment recommendations. Its importance for supporting the invasive procedures in the catheterization laboratory is less well known. Due to enhanced soft tissue characterization, it complements fluoroscopy and invasive angiography and thus enormously improves the safety of the procedures. In addition, it allows individualized follow-up care. The current article gives an overview of the clinically most frequently used procedures.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 2873­2926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is "0" and not "-". The corrected table is shown below.

[Diagnosis and treatment of aortic diseases : new guidelines of the European Society of Cardiology 2014]. / Diagnostik und Therapie von Aortenerkrankungen : Neue Leitlinien der Europäischen Gesellschaft für Kardiologie 2014.

In September 2014 the European Society of Cardiology issued guidelines for the diagnosis and treatment of aortic diseases in adults. Contrast-enhanced computed tomography (CT) represents the imaging modality of first choice as it is rapidly and almost ubiquitously available and can evaluate the entire aorta in a single-step examination. In patients with a high clinical suspicion of an acute aortic syndrome based on (family) history and symptoms, CT should be performed without further delay to confirm or refute the diagnosis. Diseases involving the ascending aorta remain a domain of open surgery, be it on an emergency basis in an acute type A dissection or electively in asymptomatic aneurysms with an aortic diameter >5.5 cm. The presence of risk factors (e. g. bicuspid aortic valve, Marfan syndrome and aortic dissection/rupture in the family history) may prompt earlier surgical repair at a lower threshold diameter. The treatment of descending aortic disease is primarily conservative including modification of cardiovascular risk factors. If indicated, endovascular aortic stent graft repair appears to be superior to open surgery for descending thoracic aortic disease or equivalent in the treatment of infrarenal abdominal aortic aneurysms. The management of aortic diseases related to genetic connective tissue diseases (e. g. Marfan syndrome, Loeys-Dietz syndrome and Ehlers-Danlos syndrome) is complex and requires special multidisciplinary expertise.

Transfemoral aortic valve implantation under sedation and monitored anaesthetic care--a feasibility study.

Surgical aortic valve replacement is the conventional treatment for symptomatic aortic valve stenosis; however, the technique of transfemoral transcatheter aortic valve implantation has recently been developed for older patients at high risk for surgery. We assessed whether this procedure could be safely performed under sedation in 100 patients. Their predicted surgical mortality was 21.6% and mean (SD) age 80 (6.6) years. Sedation was provided by remifentanil infusion (0-0.2 µg.kg(-1).min(-1)) and midazolam (1-3 mg), as required. All patients were closely haemodynamically monitored throughout by an anaesthetist and inotropic drugs administered as indicated by invasive monitoring. Sedation alone was required in 83 patients; in 17 patients sedation had to be converted to general anaesthesia, mainly because of interventional complications (n = 12). All conversions to general anaesthesia occurred after successful valve implantation. Mean (SD) anaesthesia time was 31 (12) min and procedural time 107 (77) min; 30-day and 1-year all-cause mortality were 6% and 13%, respectively. In the majority of patients, transcatheter valve implantation can safely be facilitated by sedation, provided monitoring and drug administration are carried out by an experienced cardiac anaesthetist.

[Malperfusion in aortic dissection: diagnostic problems and therapeutic procedures]. / Malperfusion bei Aortendissektion: Diagnostische Probleme und therapeutische Möglichkeiten.

Malperfusion of the thoracoabdominal aorta and its side branches is a common complication of aortic dissection, often proving fatal. Vital organ malperfusion accompanying acute aortic dissection is a major cause of mortality and morbidity and requires timely reperfusion of the ischemic organs as well as adequate management of the aortic dissection. Ischemic damage to vital organs supplied by the thoracoabdominal aorta greatly increases the overall risk of aortic dissection. As initial symptoms may be subtle, malperfusion tends to be recognized late, and therefore accounts for a considerable percentage of fatalities.Effective reperfusion is not readily achieved by central aortic surgery alone in a certain number of patients. Various strategies have been used, including entry closure by central aortic surgery or stent grafting, surgical or catheter fenestration, bypass grafting and percutaneous stenting.Endovascular bare-metal stent placement is an attractive and promising treatment option since it is readily available, is less invasive and presents fewer risks to the patient.

[Successful treatment of secondary aortoesophageal fistula after thoracic endovascular aortic repair]. / Erfolgreiche Therapie einer sekundären aortoösophagealen Fistel nach Implantation eines endovaskulären Aortenstentgrafts.

HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome. DIAGNOSTIC ASSESSMENT: CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation. THERAPY AND OUTCOME: Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient. CONCLUSION: Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.

Complex acute dissection of the aortic arch--a novel hybrid concept for one stage surgical repair.

Acute aortic dissection is a life threatening disease, which is occasionally limited to an ascending aorta only (DeBakey type II). In majority of patients it involves the aortic arch and entire rest of the aorta (DeBakey type I). The standardized cannulation and operation strategy can not be used in cases, when aortic arch branches are involved in dissection (complex aortic arch dissection) or in cases with malperfusion or severely compromised hemodynamics (tamponade or heart failure due to severe aortic valve insufficiency). The aim of this present review is to present the "Essen" treatment concept of complicated acute aortic arch dissection from diagnostics to operation strategy.

Role of echocardiography in the diagnosis of acute aortic syndrome.

Acute aortic syndrome (AAS) comprises a variety of pathologically distinct life-threatening conditions such as aortic dissection, intramural hematoma (IMH) of the aorta, penetrating aortic ulcer (PAU), traumatic transection as well as symptomatic aortic aneurysm. Patients presenting with AAS require immediate diagnosis in order to rapidly initiate adequate therapeutic measures. Echocardiography is a rapidly available imaging technique which detects AAS with high sensitivity and specificity. Compared to computed tomography (CT) and magnetic resonance imaging (MRI), echocardiography allows emergency examination of unstable patients at bedside or even directly in the operating room. Transthoracic echocardiography (TTE) may be used initially in the emergency setting to gain information about left ventricular function as well as the presence of aortic regurgitation and pericardial effusion, but has only limited diagnostic accuracy for diagnosing AAS. Transoesophageal echocardiography (TOE) is used to directly visualise the aortic pathology in both the ascending and descending aorta. This article reviews the role of echocardiography in the emergency assessment of patients presenting with acute aortic syndrome.

Intramural hematoma and penetrating ulcers: indications to endovascular treatment.

Intramural hematoma (IMH) of the aorta and penetrating aortic ulcer (PAU) are important variant forms of classic double-barrel aortic dissection in patients presenting with acute aortic syndrome. Recent insights provided by modern high-resolution imaging are currently challenging previous pathophysiologic concepts underlying IMH and PAU, suggesting a close relationship of both entities. Thoracic endovascular aortic repair (TEVAR) offers a less invasive approach to the treatment of affected patients with very encouraging early to midterm results. This review discusses current indication for TEVAR in IMH and PAU patients in the view of an improved understanding of these diseases.

Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution.

BACKGROUND: In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography. METHODS: Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality). RESULTS: During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced. CONCLUSIONS: Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.

Detection of inflammation in patients with acute aortic syndrome: comparison of FDG-PET/CT imaging and serological markers of inflammation.

OBJECTIVE: A substantial number of patients with acute aortic syndrome (AAS) require invasive therapy because of disease progression. Our study aimed to assess the impact of positron emission tomography (PET)/computed tomography (CT) and serological markers of inflammation to identify patients at high risk for disease progression. METHODS: 33 patients with AAS (thoracic aortic aneurysm 5, thoracic aortic dissection 14, penetrating aortic ulcer 8, intramural haematoma 6) were included. After intravenous administration of [18F] fluorodeoxyglucose a non-contrast enhanced PET/CT of the body trunk and CT angiography of the entire aorta was performed. Serological levels of D-dimers and C-reactive protein (CRP) were measured in all patients. Follow-up imaging was performed to detect disease progression. RESULTS: 11 (33%) of 33 patients showed elevated tracer uptake within the aortic pathology, whereas 22 patients were PET-negative. In 23 patients a CRP level exceeding 1.0 mg/dl or a D-dimer level larger than 250 microg/l was found. The follow-up time was 224 (195) days. Nine of 11 PET-positive patients (82%) showed progression of AAS. In contrast, 55% of PET-negative patients showed stable disease or regression during the follow-up period. Kaplan-Meier analysis showed a clear, but not yet significant trend to longer survival in PET-negative patients, whereas elevated CRP and D-dimers did not allow for distinguishing of high-risk patients. CONCLUSIONS: Vessel wall inflammation was found in one-third of the patients with AAS and this patient group seems to have a high risk for disease progression. These initial results needs further investigation.

Randomized comparison of effects of suture-based and collagen-based vascular closure devices on post-procedural leg perfusion.

BACKGROUND: Vascular closure devices (VCD) are well established to facilitate hemostasis after cardiac catheterization procedures. However, impairment of flow due to the reduction of femoral artery diameter remains a major concern. The present study aims to evaluate leg perfusion before and after application of collagen- and suture-based vascular closure devices. METHODS: A total of 366 patients (age: 64.3 years+/-10.7, male: 71.3%) were randomized to receive femoral access site closure with either a collagen-based closure device (group A) (n=214) or a suture-mediated device (group B) (n=152), immediately following coronary catheterization procedures. In all patients, the ankle-brachial-index (ABI) was measured before and the day after closure device application. RESULTS: In group A, mean ABI at baseline was 1.09+/-0.2, in group B 1.11+/-0.2. In both groups, there was a significant, albeit clinically not relevant, reduction in post-procedural ABI (group A: 1.04+/-0.2, p<0.01 vs baseline, group B: 1.06+/-0.2, p<0.01 vs baseline). DeltaABI was not different between both VCD groups (p=0.55). In patients with peripheral vascular disease (PVD), neither the Angioseal device (mean ABI at baseline 0.76+/-0.1) nor the Perclose-device (mean ABI at baseline 0.79+/-0.1) induced a remarkable impairment of leg perfusion (Angioseal: 0.77+/-0.1, p=0.9 vs baseline, Perclose: 0.78+/-0.1, p=1.0 vs baseline). Clinically, no aggravation of claudication was observed in the PVD patient group. CONCLUSION: Both vascular closure devices are not associated with clinically relevant reduction in ABI. There was no difference between the two groups with respect to the level of flow impairment. Both devices may be safely used in patients with reduced ABI.

Gadolinium as an alternative contrast agent during cardiac catheterization in patient with iodine-induced hyperthyroidism.

We report the first case of a male patient with iodine-induced hyperthyroidism and unstable angina pectoris in whom a diagnostic cardiac catheterization with gadolinium as contrast agent was chosen. The patient was hospitalized with an iodine-induced hyperthyroidism after angioplasty using an iodinated contrast agent. He presented with a continuous arrhythmia and unstable angina pectoris. A repeated cardiac catheterization using iodinated contrast agent was contraindicated. This case report shows that gadolinium is a useful alternative contrast agent for cardiac intervention in patients with iodine-induced hyperthyroidism.

[Stent-graft implantation in the thoracic aorta. Results of an interdisciplinary survey in Germany]. / Thorakale Aorten-Stentgraftimplantation. Ergebnisse einer interdisziplinären Umfrage in Deutschland.

BACKGROUND AND OBJECTIVE: Endovascular stent-graft placement is emerging as a novel therapeutic option in patients with disease of the descending thoracic aorta. Quality standards for performing stent-graft procedures as well as for pre- and postoperative patient management are lacking, so far. It was the aim of this present survey to assess the current therapeutic standard of thoracic aortic stent-graft placement in Germany. METHODS: In a nationwide survey, a total of 206 vascular surgical, radiologic, cardiologic, and cardiothoracic surgical departments were contacted. Data concerning preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized questionnaire comprising 29 items. Data analysis was performed using univariate analysis. RESULTS: 184 (89.3 %) of the 206 departments participated in the survey. Of these, 71 centers reported intending to perform or having performed thoracic aortic stent-graft placement. The survey overall represents 2267 endovascular stent-graft procedures performed in Germany between 1997/98 and 2003. On average, 7.4 stent-graft procedures/year were performed by each center, with half the centers performing fewer than 5 procedures/year. Thoracic aortic aneurysms was the main indication for endovascular stent-graft placement, followed by aortic dissection. There were significant differences between the different medical specialties which perform stent-graft procedures with respect to indications, choice of preoperative and intraoperative imaging methods, and technical equipment. There was strong agreement between the different centers concerning the necessity of a life-long follow-up after stent-graft placement, with computed tomography being the preferred imaging technique (90 % of centers). CONCLUSION: The present survey documents an increasing use of endovascular stent-graft placement in patients with disease of the descending thoracic aorta. There were differences regarding the technical execution of this procedures between specialties with respect to indication, procedure planning, and practical-technical aspects of stent-graft placement.

[MR coronary angiography with MS-325, a blood pool contrast agent: comparison of an inversion recovery steady-state free precession with an inversion recovery fast low angle shot sequence in volunteers]. / MR-Koronarangiographie mit MS-325, einem Blood-Pool-Kontrastmittel: Vergleich einer Inversion Recovery Steady-State Free Precession und einer Inversion Recovery Fast Low Angle Shot Sequenz in Probanden.

PURPOSE: To compare the signal-to-noise and contrast-to-noise ratio as well as the image quality of 3D inversion recovery steady-state free precession (IR-SSFP) and 3D inversion recovery fast low angle shot (IR-FLASH) sequences for contrast-enhanced breath-hold MRCA. MATERIALS AND METHODS: 24 healthy volunteers (10 female, 14 male, mean age 29.8 +/- 6.1 years) were involved in this study. All examinations were performed on a 1.5 T MR scanner (Magnetom Sonata, Siemens, Germany) after injection of 0.05 mmol/kg body weight MS-325 (EPIX Pharmaceuticals, Cambridge, MA and Schering AG, Berlin, Germany). MRCA was performed using IR-SSFP (TR 3.8 ms, TE 1.6 ms, FA 65 degrees , 35 phase encoded steps, bandwidth 540 Hz/pixel, slice thickness 1.5 mm, in-plane resolution 1.2 x 0.9 - 1.4 x 1.0 mm) and IR-FLASH (TR 3.8 ms, TE 1.6 ms, FA 25 degrees , bandwidth 490 Hz/pixel, slice thickness 1.5 mm, in-plane resolution 1.2 x 0.9 - 1.4 x 1.0 mm) sequences. For all scans the inversion time was set to null the signal intensity of the myocardium. Signal-to-noise ratio (SNR) as well as contrast-to-noise ratio (CNR) measurements (blood versus myocardium) were performed. The image quality was assessed based on a 5-point scale ranging from 1 (excellent) to 5 (non-diagnostic) by two radiologists in consensus. RESULTS: The mean signal-to-noise ratio of blood (27.7 +/- 4.7 vs. 22.6 +/- 4.9, P < 0.0001) and the contrast-to-noise ratio (21.0 +/- 4.3 vs. 15.8 +/- 4.3, P < 0.0001) showed significantly higher values for IR-SSFP sequences. The mean image quality scores were significantly higher for SSFP (3.6 +/- 0.7) than FLASH (2.8 +/- 0.9) sequences (P < 0.05). CONCLUSION: IR-SSFP sequences show a considerable overall improvement in image quality compared to IR-FLASH sequences for MRCA after injection of a gadolinium-based blood pool contrast agent.