[Echocardiographic imaging of the tricuspid valve]. / Echokardiographische Bildgebung der Trikuspidalklappe.

Pathologies of the right heart and the tricuspid valve were not recognized to be of prognostic relevance for many years. Available evidence showing the progressive nature of right heart diseases with direct impact on patient survival have changed current understanding of its clinical importance. Visualization and a profound understanding of the right heart anatomy are prerequisites for the development of modern and still experimental treatment strategies. Transthoracic and transesophageal echocardiography enable a standardized and clear visualization and assessment of the right heart anatomy and its pathological changes.

Heart Rate Variability and Arrhythmic Burden in Pulmonary Hypertension.

A growing body of evidence indicates that sudden cardiac death constitutes a major cause of mortality in pulmonary hypertension (PH). As validated method to evaluate cardiac autonomic system dysfunction, alterations in heart rate variability (HRV) are predictive of arrhythmic events, particularly in left ventricular disease. Here, we sought to determine the clinical value of HRV assessment in PH. Sixty-four patients were allocated to different PH-subgroups in this prospectively conducted trial: 25 patients with pulmonary arterial hypertension (PAH), 11 patients with chronic thromboembolic PH (CTEPH), and 28 patients with COPD-induced PH. All patients underwent 24-h Holter electrocardiogram for HRV assessment by time- and frequency-domain analysis. Arrhythmic burden was evaluated by manual analysis and complementary automatic measurement of premature atrial and ventricular contractions. The results were compared to 31 healthy controls. The PAH patients offered a significantly higher mean heart rate (78.6 ± 10.4 bpm vs. 70.1 ± 10.3 bpm, p = 0.04), a higher burden of premature ventricular contractions (p < 0.01), and decreases in HRV (SDNN: p < 0.01; SDANN: p < 0.01; very low frequency: p < 0.01; low frequency/high frequency ratio: p < 0.01; total power: p = 0.02). In CTEPH patients, only the amount of premature ventricular contractions differed from controls (p < 0.01), whereas in COPD both premature atrial contraction count and frequency-domain-based HRV manifested significant differences. In conclusion, PAH appears to be primarily affected by HRV alterations and ventricular arrhythmic burden, indicating a high risk for malignant arrhythmic events.

Obstructive Sleep Apnea Is Related to Increased Arterial Stiffness in Ultrasound Speckle-Tracking Analysis.

Obstructive sleep apnea (OSA) is an independent risk factor for atherosclerosis. The aim of our study was to determine arterial stiffness in OSA patients by means of the ultrasound speckle-tracking-based method. Twenty six OSA patients and 17 control subjects were enrolled in the study. The speckle-tracking-based analysis of carotid artery included circumferential strains, circumferential strain rates, radial displacement, and radial strain rates. We found that the global average circumferential strains, circumferential strain rates, and radial displacement were significantly lower in OSA patients compared to controls (2.19 ± 0.30 % vs. 4.17 ± 0.33 %, 0.22 ± 0.03 l/s vs. 0.31 ± 0.02 l/s, 0.10 ± 0.01 mm vs. 0.16 ± 0.02 mm, respectively, p < 0.05 for all). There were no significant differences in radial strain rates between the groups (0.32 ± 0.04 % vs. 0.33 ± 0.01 %). We conclude that OSA is associated with an increased arterial stiffness.

Atherosclerotic Vessel Changes in Sarcoidosis.

Sarcoidosis is a systemic granulomatous disease. Atherosclerosis is a chronic inflammatory vessel disease. The aim of our present study was to investigate whether sarcoidosis could be associated with increased risk of atherosclerotic vessel changes. Angiological analysis and blood tests were performed in 71 sarcoidosis patients and 12 matched controls in this prospective cross-sectional study. Specifically, angiological measurements comprised ankle brachial index (ABI), central pulse wave velocity (cPWV), pulse wave index (PWI), and duplex sonography of central and peripheral arteries. Sarcoidosis activity markers (angiotensin converting enzyme, soluble interleukin-2 receptor) and cardiovascular risk parameters such as cholesterol, lipoprotein(a), C-reactive protein, interleukin 6, fibrinogen, d-dimer, and blood count were analyzed in blood. We found no relevant differences in ABI, cPWV, and plaque burden between the sarcoidosis and control groups (1.10 ± 0.02 vs. 1.10 ± 0.02, 6.7 ± 0.5 vs. 6.1 ± 1.2, 53.7 % vs. 54.5 %, respectively). However, PWI was significantly higher in sarcoidosis patients (146.2 ± 6.8) compared with controls (104.9 ± 8.8), irrespectively of the activity of sarcoidosis and immunosuppressive medication. Except for increased lipoprotein(a) and d-dimer in sarcoidosis, the remaining cardiovascular markers were similar in both groups. We conclude that sarcoidosis is associated with increased pulse wave index, which may indicate an early stage of atherosclerosis.

Pulmonary hypertension in HIV infection: a prospective echocardiographic study.

OBJECTIVES: While idiopathic pulmonary arterial hypertension (PAH) is a rare disease, it is seen more frequently in patients with HIV infection. The aim of this study was to evaluate the prevalence of pulmonary hypertension (PH) in patients with HIV infection by echocardiographic screening. METHODS: Echocardiography and N-terminal of the prohormone brain natriuretic peptide measurement were used to examine the prevalence of PH prospectively in HIV-positive patients (n = 374) during routine follow-up visits for HIV disease. RESULTS: In echocardiographic screening, PH was detected in a total of 23 of 374 HIV-infected patients (6.1%). Of these, three patients (13%) presented with symptoms of dyspnoea and fatigue, and diagnosis of PAH was confirmed by right heart catheterization. Patients with systolic pulmonary artery pressure (sPAP) > 30 mmHg were more likely to be female, to have a history of injecting drug use and to originate from high-prevalence countries (HPCs). CONCLUSIONS: Echocardiographic screening detected PH in a substantial proportion of HIV-positive patients. Female gender, a history of injecting drug use and HPC origin were associated with a higher prevalence of HIV-associated PH. The relevance and long-term outcome of these findings need to be validated in follow-up studies, which are ongoing.

[New therapeutic approaches to pulmonary embolism: trials' results and significance of direct oral anticoagulants]. / Neue Therapieoptionen zur Behandlung der Lungenembolie: Studienlage und Stellenwert der direkten oralen Antikoagulantien.

Venous thromboembolisms (VTE) are frequently encountered emergencies that sometimes run a fatal course. Diagnostic and therapeutic strategies in patients with suspected pulmonary embolism (PE) are based on the presence of shock and hypotension. Oral anticoagulation is recommended for at least three months, extended anticoagulation should be considered for patients with unprovoked PE and low bleeding risk. As an alternative to vitamin K antagonists, direct oral anticoagulants are recommended. The present review discusses the mode of action, current data, and the status of rivaroxaban, dabigatran, apixaban and edoxaban in the treatment of PE - taking into account the new guidelines of the European Society of Cardiology and their clinical implementation.

Reduction of severe mitral regurgitation with the MitraClip system improves renal function in two patients presenting with acute kidney injury and progressive renal failure due to cardio renal syndrome.

Mitral regurgitation (MR) is a frequent valve disorder in elderly patients, often accompanied by multiple comorbidities such as renal impairment. In these patients percutaneous mitral valve (MV) repair has become an established treatment option but the role of MR on renal dysfunction is not yet well defined. We here report on two cases presenting with severe MR and progressive renal failure caused by cardio renal syndrome, in which percutaneous MV treatment with the MitraClip system significantly improved renal function. These findings suggest that interventional MV repair can prevent progression of renal deterioration in patients suffering from combined advanced heart and renal failure. Further clinical studies are necessary to support our finding and to answer the question whether optimizing renal function by implantation of the MitraClip device is also of prognostic relevance in these patients.

Innovations and novel technologies in TAVI. Second generation transcatheter heart valves.

Transcatheter aortic valve implantation (TAVI) is the new standard-of-care for inoperable patients with superior outcome compared to conservative management including balloon valvuloplasty. In high-risk patients, TAVI has shown non-inferiority compared with surgical aortic valve replacement. Although data from national multi-centre registries are very encouraging and use of TAVI in intermediate risk patients has been discussed, it is of note that the commercially available and currently used transcatheter heart valves (THV) have not yet been assessed by randomized clinical trials in those patients. New technology advances promise to simplify TAVI and to improve outcome by reducing the rate of TAVI-specific issues such as paravalvular aortic regurgitation (PAR), annular rupture, and conduction disturbances. A reduction in the incidence and severity of PAR represents an obvious target for technical improvements in the design of upcoming "next generation" THVs and of implantation techniques including repositioning/recapturing features, paravalvular sealing techniques, and precise peri-interventional imaging modalities.

[Ischemic mitral regurgitation : pathomechanisms and current therapeutic options]. / Ischämische Mitralklappeninsuffizienz : Pathomechanismen und aktuelle Therapieoptionen.

Ischemic mitral regurgitation (MR) is a complication of myocardial infarction due to coronary heart disease and may occur during the course of acute ischemia or delayed following adverse left ventricular remodeling. Acute ischemic MR represents a life-threatening condition and requires immediate surgical correction. Chronic ischemic MR develops time-delayed from acute ischemia and is caused by pathological remodeling of the left ventricle or valvular apparatus and mostly affects older patients with severe comorbidities. This common manifestation of ischemic MR contributes to the poor prognosis of such patients. Therapeutic options for the treatment of patients with chronic ischemic MR are limited as current guidelines are based on weak evidence and the optimal treatment is still a matter of controversy. Surgical correction of chronic ischemic MR is only advised in patients with indications for concomitant surgical revascularization and modern interventional or surgical treatment strategies to reduce MR are not included in these guidelines. Modern surgical options and new interventional procedures are available and will influence future treatment strategies of this chronic manifestation of MR.

[Traumatic tricuspid valve insufficiency with right-to-left shunt: bridging using extracorporeal venovenous membrane oxygenation]. / Traumatische Trikuspidalklappeninsuffizienz mit Rechts-links-Shunt: "Bridging" mithilfe der extrakorporalen venovenösen Membranoxygenierung.

The case of a young male motor vehicle driver is reported who suffered multiple trauma in a car accident with pulmonary and cardiac contusions. In the course of severe pneumonia and traumatic tricuspid valve insufficiency a right-to-left shunt with refractory hypoxemia developed across a pre-existing atrial septal defect (ASD). The patient could be successfully treated by the combination of extracorporeal membrane oxygenation for bridging, interventional ASD occlusion and in the long-term by operative reconstruction of the tricuspid valve.

[Pulmonary hypertension in end-stage renal disease: three case reports]. / Pulmonale Hypertonie bei terminaler Niereninsuffizienz: Drei Kasuistiken.

HISTORY: Within three months, three patients with end-stage renal disease presented for evaluation of pulmonary hypertension (PH): a 72-year-old woman (case 1), a 67-year-old patient (case 2) and a 75-year-old patient (case 3), each with increasing dyspnea (WHO functional class III). INVESTIGATIONS: In all three cases, there was echocardiographic evidence of right heart failure; right heart catheterization was completed before and after dialysis. In case 1, we found a postcapillary PH (PH group 2 - PH with left heart diseases/diastolic dysfunction). Case 2 also showed a postcapillary PH and a high cardiac output of 9.7 l/min. In case 3, unmasked after dialysis, a precapillary, pulmonary arterial hypertension (PAH - group 1) was detected. TREATMENT AND COURSE: In patient 1, no relevant improvement of symptoms was observed, despite optimized cardiac therapy. There was a significant clinical improvement in patient 2 after surgical reduction of the arteriovenous shunt. In patient 3, relevant clinical and hemodynamic improvement was seen under treatment with bosentan. CONCLUSION: These cases confirm the role of right heart catheterization in the differential diagnosis of unclear PH in patients with end-stage renal failure. Moreover, the three cases point to three different causes. Specific therapies can result in significant symptomatic improvement.

[Pulmonary hypertension due to left heart disease: recommendations of the Cologne Consensus Conference 2010]. / Pulmonale Hypertonie bei Linksherzerkrankungen: Empfehlungen der Kölner Konsensus-Konferenz 2010.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more frequent forms of PH such as PH due to left heart disease. Despite the lack of data, targeted PAH treatments are increasingly being used for PH associated with left heart disease. This development is of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease, so that it may be speculated whether selected patients may benefit from targeted PH therapy. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH due to left heart disease. This commentary summarizes the results and recommendations of this working group.

Bridging of chronic oral anticoagulation with enoxaparin in patients with atrial fibrillation: results from the prospective BRAVE registry.

Current American College of Chest Physicians (ACCP) guidelines on the perioperative management of oral anticoagulation (OAC) suggest bridging therapy with therapeutic doses of low-molecular-weight heparin (LMWH) in patients with atrial fibrillation (AF) if at high or moderate thromboembolic (TE) risk, and with reduced doses in patients with low TE risk. Our objective was to assess the efficacy and safety of bridging OAC with enoxaparin in AF patients. These are the results of an open, prospective monocenter register. Hospitalized and ambulatory patients with AF requiring bridging therapy at high or moderate TE risk and normal renal function were treated with therapeutic LMWH doses; all other patients received reduced doses. A total of 703 patients were enrolled, of whom 358 (50.9%) were at moderate-to-high and 345 (49.1%) at low TE risk. Renal impairment was detected in 308 patients (43.8%). One hundred ninety patients (27.1%) were treated with therapeutic LMWH doses and 513 (72.9%) with reduced doses. No TE events were observed during the follow-up period (0%; 95% confidence interval [CI] 0.0-0.52). Three major bleeds (0.4%; 0.1-1.2) and 60 minor bleeds were noted (8.9%; 6.6-10.9). Age and total LMWH doses were risk factors for bleeding in the multivariate analysis. The study, under conditions of everyday clinical care, supports a predefined bridging regimen based on the individual patient's TE risk and renal function. Patients with low TE risk or with impaired renal function can be bridged effectively and safely with reduced LMWH doses.

Symptomatic paravalvular leakage after mechanical aortic valve replacement in a critically ill patient: why not just "plug" the hole?

We report on an 81-year old man with decompensated severe aortic regurgitation due to a large paravalvular leakage of mechanical aortic valve prosthesis. Because of relevant co- morbidities the patient was unable to undergo cardiovascular surgery. Non- invasive imaging allowed exact localization of the leakage and sizing of the defect diameter; therefore, we decided to perform interventional closure of the defect using the Amplatzer Vascular Plug III device. The intervention was guided by transoesophageal echocardiography. Afterwards the patient's medical condition improved continuously. Follow up echocardiography showed stepwise decrease in severity of aortic valve insufficiency. These findings illustrate, first, that echocardiography is extremely helpful to select patients which may benefit from interventional closure of a paravalvular leakage after valve replacement. Secondly, non-invasive imaging is indispensable during such a complex intracardiac procedure to guide the intervention. Thirdly, the TEE findings during follow-up demonstrate nicely that acute implantation of the device is followed by a subsequent 'healing' process (including thrombus/scar formation and endothelialization) which is mainly responsible for successive defect closure.

Monitoring therapeutic anticoagulation with low molecular weight heparins: is it useful or misleading?

Weight adapted low molecular weight heparin (LMWH) treatment is recommended as initial anticoagulant therapy of deep vein thrombosis, pulmonary embolism, in patients with myocardial ischemia or when oral anticoagulation (OAC) must be interrupted peri- operatively. Traditionally unfractioned heparin (UFH) was used as standard short acting anticoagulant, with the therapy monitored by frequent laboratory testing. Currently LMWH have broadly replaced UFH as first- choice anticoagulant due to more preferable pharmacokinetics and a better safety profile. Therapeutic anticoagulation with LMWH can be achieved by subcutaneous weight adapted application and measurement of anti-factor Xa- activity (anti-Xa) has been established as gold standard for LMWH- monitoring. However, since almost all LMWH dosing regimens have been developed empirically without laboratory monitoring, there is still a debate ongoing about the usefulness and impact of anti-Xa-testing. Data are lacking that prove a clear correlation between obtained levels of anti-Xa and the patients' clinical outcome. Newer methods have been developed aiming to determine a broader spectrum of LMWH depending anticoagulant activity. Even though there are some promising preliminary results, these alternative methods are not ready for routine clinical use yet. Nevertheless, current guidelines advise determination of anti-Xa in special patient populations with markedly altered LMWH metabolism or to exclude residual LMWH- activity before surgery at very high risk of bleeding. The aim of this article is to review critically the usefulness of anti- Xa guidance of LMWH- therapy and to give new perspectives on upcoming methods of LMWH- monitoring.

Biliary metal stents and air embolism: a note of caution.

Metal stents are a valuable treatment modality for patients with biliary obstruction. However, we present here two patients whose cases may serve as a warning about an unusual complication associated with these stents. We encountered this complication after endoscopic retrograde cholangiography for obstructed metal biliary stents. The first patient, an 87-year-old man with a benign biliary stricture, failed to regain consciousness after clearing of his stent using a Dormia basket and balloon catheter. Cerebral air embolism was diagnosed on cerebral computed tomography, and transesophageal echocardiography revealed a patent foramen ovale as a precipitating factor for paradoxical air embolism. He survived and was discharged with a residual hemiparesis. In the second patient, a 54-year-old man who had a history of a Billroth II operation and chronic pancreatitis and who had a portal cavernoma with biliary obstruction due to collateral veins, electromechanical dissociation complicated the balloon-catheter stent revision. Echocardiography performed during cardiopulmonary resuscitation showed major air embolism to the right heart. The patient died. These cases demonstrate that air may gain access to the venous system during therapeutic endoscopic procedures of this type. It is likely that the large diameter of metal stents and the potential for these stents to lacerate venous structures facilitate the entry of air into the venous circulation, an event which may have life-threatening consequences.

[Interventional catheter closure of persistent foramen ovale (PFO) in a patient with paradoxical embolism and Brugada's syndrome]. / Katheterinterventioneller PFO-Verschluss bei einem Patienten mit paradoxer Embolie und Brugada-Syndrom.

HISTORY AND ADMISSION FINDINGS: A 41-year-man was admitted because of acute bluish-grey skin discoloration in cold sensation in the right hand. His brother had suffered sudden cardiac death, aged 42 years. INVESTIGATIONS: Angiography demonstrated embolic occlusion of the digital artery of the right thumb. Transesophageal echocardiography showed a persistent foramen ovale (PFO) with an aneurysm of the atrial septum (ASA) with marked right-to-left shunt of contrast medium during a Valsalva maneuvre as well as two smaller septal fenestrations. There was no evidence of any other source of embolism. The resting electrocardiogram showed an incomplete right bundle branch block with ST elevations in V (1)-V (3), changes like those described in Brugada's syndrome. TREATMENT AND COURSE: Paradoxical embolism having been demonstrated, the PFO with ASA were closed with a percutaneously introduced Helex septum occluder. Later an implantable cardioverter-defibrillator (ICD) was introduced. CONCLUSIONS: A PFO, particularly if associated with an atrial aneurysm, is an important site of paradoxical embolism. In symptomatic patients percutaneous transcatheter septal occlusion should be considered preceding any ICD insertion thought necessary for concurrent Brugada's syndrome.