Acute outcome of chronic total occlusion (CTO) recanalizsation in the elderly.

OBJECTIVES: Percutaneous coronary intervention (PCI) of total chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. There is only insignificant knowledge reported in the literature about age differences in CTO recanalization. We analyzed in this study the issue of the impact of age on procedural characteristics, complications and short-term outcome. METHODS: Between 2012-2016 we included 440 patients. They underwent PCI for at least one CTO. Antegrade and retrograde CTO techniques were applied. The retrograde approach was used only after failed antegrade intervention. Continuous data are presented as the mean ± standard deviation; categorical data are presented as numbers and percentages unless otherwise specified. We used Twosamplet- t-test with equal variance to test the significant differences of the variables between the two cohorts. RESULTS: Procedural success proved independently of age. There was no significant interaction between age and procedural success (p=0.5). Complication rates were low in both groups (2.7% vs. 4%; p=0,4) with no difference in statistical significance. CONCLUSIONS: Our study suggests that in an aging society patients with severe coronary artery disease and chronical total occlusions an interventional therapy should be used more intensively. It can be performed safe and feasible.

Gender-based acute outcome in percutaneous coronary intervention of chronic total coronary occlusion.

BACKGROUND: Percutaneous coronary intervention (PCI) of total chronic coronary occlusion (CTO) still remains a major challenge. Insignificant data are reported in the literature about gender differences in CTO-PCI in the era of new drug-eluting stents. In this study we analysed the impact of gender on procedural characteristics, complications and acute results. METHODS: Between 2010-2015 we included 780 consecutive patients. They underwent PCI for at least one CTO. Antegrade and retrograde CTO techniques were applied. RESULTS: Patients undergoing CTO-PCI were mainly men (84%). Male patients were younger (66.9 years ±10.6 vs. 61.1 years ±10.4; p < 0.001), more often smokers, but less frequently had a history of coronary artery disease (24.4% vs. 32.7%; p = 0.085) compared with female patients. Female patients more often had diabetes mellitus (29.6% vs. 26.7%; p = 0.55) and hypertension (82.7% vs. 80.7%; p = 0.55). There were no differences with respect to the amount of contrast fluid, fluoroscopy time and examination time as well as to the length of the stent or the number of the stents. The stent diameter was slightly smaller in women, which was not surprising because the lumen calibre tends to be smaller in women than in men (3.0 mm (2.5-3) vs. 3.0 mm (3-3.5); p < 0.001). The success rates were 81.0% in women and 80.1% in men. There was no significant interaction between gender and procedural success and complication rates. CONCLUSIONS: Our retrospective study suggests that women and men have a comparable success rate at a low complication rate after recanalisation of CTO.

Validity of the J-CTO Score and the CL-Score for predicting successful CTO recanalization.

BACKGROUND: Percutaneous coronary intervention (PCI) of total chronic coronary occlusion (CTO) still remains a major challenge in interventional cardiology. To predict the probability of a successful intervention different scoring systems are available. We analyzed in this study the validity of two scoring systems, the Japanese CTO score (J-CTO score) and the newly developed Clinical and Lesion-related score (CL Score). METHODS: Between 2012 and 2015 we included 379 consecutive patients. They underwent PCI for at least one CTO. Antegrade and retrograde CTO techniques were applied. The retrograde approach was used only after failed antegrade intervention. RESULTS: Patients undergoing CTO PCI were mainly men (84%). The overall procedural success rate was 84% (±0.4). The mean J-CTO score was 2.9 (±1.3) and the mean CL score was 4.3 (±1.7). The CL score predicted more precisely the interventional results than the J-CTO score. CONCLUSIONS: Our study suggests that the previously presented CL score is superior to the J-CTO score in identifying CTO lesions with a likelihood for successful recanalization. Generally it appears to be a helpful tool for selecting patients and identifying the appropriate operator.

[Carotid sinus massage - who is allowed to do it?]. / Carotis-Sinus-Massage - Wer darf sie anwenden?

Although carotid sinus massage (CSM) belongs to the basic knowledge of every physician, there are no universally valid and structured guidance on the nature of the implementation and application. We analyzed the existing guidelines and literature in light of who is allowed to perform CSM. In summary, there are two indications for CSM: As part of diagnostic tools to clarify underlying pathology of syncope CSM should be performed only by an experienced physician with ECG control and after sonographic exclusion of carotid atherosclerosis if no other explanations are reasonable. In case of supraventricular tachycardia CSM may be used by any physician without prior sonography of the carotids to terminate the tachycardia before any pharmacological strategies are performed.

Determination of the coronary flow reserve of the LAD in patients with HOCM using the intracoronary Doppler catheter.

OBJECTIVE: Hypertrophic obstructive cardiomyopathy (HOCM) is still a serious problem that is characterized by an increasing hypertrophy of the cardiac muscle. The aim of this study was to investigate the hypothesis whether in HOCM the coronary flow reserve in the left anterior descending artery (LAD) is influenced by pharmacologic stimulation or stimulation using a pacemaker. PATIENTS AND METHODS: The study was carried out in 15 patients (6 male, 9 female) with the typical echocardiographic signs of HOCM without coronary artery disease. Using an intracoronary Doppler catheter the average peak velocity and the absolute coronary flow reserve were determined in the proximal, medial and distal part of the LAD under influence of Papaverine, Substance P and under pacemaker stimulation. The coronary square plane was calculated angiographically under the influence of Substance P. Moreover, the retrograde flow was studied and the coherence between the increase of the coronary square plane and the coronary flow reserve were investigated. For statistical analysis the mean value, the standard error of the mean, Spearman's correlation coefficient and the t-test were calculated. RESULTS: Under pharmacologic stimulation higher values in the average peak velocity were observed compared to pacemaker stimulation. A retrograde flow was observed in 8 out of 10 patients. The coronary flow reserve was higher under pharmacologic influence than under pacemaker stimulation. A coherence between the increase of the coronary square plane and the coronary flow reserve was not found. CONCLUSIONS: So far, from the published data concerning the characteristics of coronary flow in HOCM patients, only the retrograde flow was reproducible in our patient group. However, a decrease of the coronary flow reserve compared to a healthy control group of the literature could not be observed. Nevertheless ischemia in the subordinate vessels and on the base of microcirculation cannot be excluded.

[Idiopathic hypereosinophilia with cardiac involvement]. / Idiopathische Hypereosinophilie mit kardialer Beteiligung.

HISTORY AND CLINICAL FINDINGS: A 34-year-old previously healthy woman was admitted to another hospital because of abdominal pain, cough and dyspnea. Peripheral eosinophilia was present. Two months later she was admitted to the cardiology department with signs of mitral regurgitation. Dyspnea, fatigue, skin rashes with pruritus and a systolic murmur were noted. INVESTIGATIONS: Laboratory tests showed 11.4/nl leukocytes (normal range 4.8-10.8/nl) with an eosinophilia of 19% (normal range < 4%) corresponding to 2.2/nl. Cardiac magnetic resonance imaging revealed endomyocardial fibrosis involving the posterior mitral leaflet with resulting valvular regurgitation. Doppler ultrasound showed restrictive heart failure. DIAGNOSIS, THERAPY AND FURTHER COURSE: The diagnosis of idiopathic hypereosinophilia most likely as part of hypereosinophilic syndrome with cardiac involvement was made. The patient was treated with digitalis, diuretics and peptidyl dipeptidase (PDP) inhibitor. The treatment with glucocorticoids and cytotoxic agent to achieve a reduction of eosinophil count was ended by the patient a few weeks later. CONCLUSION: The hypereosinophilic syndrome with endomyocardial fibrosis is rare, and its prognosis is grave. The pathophysiological mechanisms are not entirely clear, nearly 70 years after Löffler first described fibrous endocarditis with eosinophilia. Patients receive symptomatic medical therapies. Additional surgical treatment has been reported,. Antihypereosinophilic therapy is used to control the disease.

[Therapy and risk-stratification in hypertrophic cardiomyopathy--a current survey]. / Therapie und Risikostratifizierung der Hypertrophen Kardiomyopathie. Ein aktueller Uberblick.

Hypertrophic cardiomyopathy (HCM) is a relatively common disease of the cardiac sarcomere with broad heterogeneity in terms of the disease-causing gene mutation, phenotypic expression, therapy and prognosis. Besides the standard drug treatment, there are several therapeutic options available for severe refractory symptomatic HCM with obstruction. Dual-chamber pacing and transcoronary ablation of septal hypertrophy (TASH) have recently emerged as alternatives to myectomy. However, myectomy remains the current gold standard of therapy for HCM until the promising initial follow-up data for TASH can be transferred into a long-term follow-up period, or prospective randomized comparative trials between these therapies are available. However, even now, TASH represents an important therapeutic alternative in patients with relevant co-morbidities and a high operative risk. Despite significant gradient reduction and amelioration of clinical symptoms, none of these treatment strategies has a proven influence on the natural history of HCM. Hence, regarding the long-term prognosis of the disease, risk stratification of sudden cardiac death using non-invasive risk assessment has become of paramount importance, while genotyping might become the determinant and stratifying marker in the near future. At present, according to secondary prevention, treatment with an implanted cardioverter-defibrillator +/- amiodarone therapy is mandatory, while according to primary prevention treatment should particularly depend on the individual risk profile.

[Attempted suicide by intravenous injection of metasystox]. / Suizidversuch durch intravenöse Injektion von Metasystox(R).

A 27-year old man was admitted to the hospital after having attempted suicide by injection of 30 ml of metasystox (demeton-s-methyl), an organophosphate compound, in a cubital vein of the left arm. He was suffering from the typical cholinergic symptoms. Local examination of the injection site revealed a local inflammation extending from the middle of the left upper arm to the distal forearm. Surgical débridement became necessary. In the third week of treatment he developed a rhabdomyolysis (CK 66.300 U/l) with an acute renal failure and needed haemodialysis. Later he showed signs of an intermediate syndrome.

[Mobilization and retrieval of an entrapped guidewire in the righ coronary artery]. / Mobilisation und Bergung eines in der rechten Koronararterie festsitzenden Führungsdrahtes.

The elective PTCA of a highly stenotic right coronary artery was complicated by intracoronary entrapment of the guidewire. After transfer to a hospital with a stand-by cardiosurgical team, the interventional mobilization and withdrawal of the wire was performed. Initially the attempt to position a balloon-catheter through the entrapped guidewire failed due to a localized radiolucent piece of material attached to the tip of the wire. After introduction of an additional guidewire and consecutive dilation of the stenosis, gradual mobilization and removal of the wire was successful. During this maneuver the distal part of the guidewire ruptured and was caught in a side branch of the right femoral artery, where it could finally be retrieved, using a conventional retrieving device in a crossover technique. Intracoronary entrapment is a rare but potentially dangerous complication during coronary interventions, every cardiologist should be aware of, especially when treating tortuous vessels.

Genetic polymorphisms in the renin-angiotensin-aldosterone system associated with expression of left ventricular hypertrophy in hypertrophic cardiomyopathy: a study of five polymorphic genes in a family with a disease causing mutation in the myosin binding protein C gene.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is an inherited disease of the sarcomere characterised clinically by myocardial hypertrophy and its consequences. Phenotypic expression is heterogeneous even within families with the same aetiological mutation and may be influenced by additional genetic factors. OBJECTIVE: To determine the influence of genetic polymorphisms of the renin-angiotensin-aldosterone system (RAAS) on ECG and two dimensional echocardiographic left ventricular hypertrophy (LVH) in genetically identical patients with HCM. PATIENTS AND METHODS: Polymorphisms of five RAAS components were determined in 26 gene carriers from a single family with HCM caused by a previously identified myosin binding protein C mutation. Genotypes associated with a higher activation status of the RAAS were labelled "pro-LVH genotypes". RESULTS: There was a non-biased distribution of pro-LVH genotypes in the gene carriers. Those without pro-LVH genotypes did not manifest cardiac hypertrophy whereas gene carriers with pro-LVH genotypes did (mean (SD) left ventricular muscle mass 190 (48) v 320 (113), p = 0.002; interventricular septal thickness 11.5 (2.0) v 16.4 (6.7), p = 0.01; pathological ECG 0% (0 of 10) v 63% (10 of 16), respectively). Multivariate analysis controlling for age, sex, and hypertension confirmed an independent association between the presence of pro-LVH polymorphisms and left ventricular mass. When each polymorphism was assessed individually, carriers of each pro-LVH genotype had a significantly greater left ventricular mass than those with no pro-LVH mutation; these associations, with the exception of cardiac chymase A AA polymorphism (p = 0.06), remained significant in multivariate analysis. CONCLUSION: Genetic polymorphisms of the RAAS influence penetrance and degree of LVH in 26 gene carriers from one family with HCM caused by a myosin binding protein C mutation.

Post-stenotic coronary blood flow at rest is not altered by therapeutic doses of the oral antidiabetic drug glibenclamide in patients with coronary artery disease.

OBJECTIVE: To investigate whether blood flow in normal and post-stenotic coronary arteries is altered by therapeutic doses of the sulfonylurea agent glibenclamide. PATIENTS: 12 patients with a high grade stenosis of the left anterior descending coronary artery (n = 10) or left circumflex coronary artery (n = 2), and an angiographically normal corresponding left circumflex artery or left anterior descending artery, respectively. DESIGN: Two Doppler ultrasound wires were positioned in the "normal" and post-stenotic artery for simultaneous measurements of coronary blood flow velocity under baseline conditions and after intravenous glibenclamide, 0.05 mg/kg body weight. Local coronary blood flow was calculated from the average peak velocity and the cross sectional area derived from quantitative coronary angiographic analysis. Coronary flow reserve was determined after intracoronary injection of 30 microg adenosine and 12 mg papaverine. RESULTS: One hour after glibenclamide, serum insulin increased from (mean (SD)) 7.4 (2.0) to 44.8 (25.5) mU/l (p < 0.005), and C peptide from 1.4 (0.4) to 3.4 (1.2) ng/l (p = 0.005). In normal coronary arteries coronary flow reserve was 2.6 (0.4) after adenosine and 3.0 (0.4) after papaverine, while in post-stenotic arterial segments it was 1.2 (0.3) after adenosine (p = 0.005) and 1.3 (0.3) after papaverine (p = 0.005). There was no significant difference after glibenclamide. In non-stenotic arteries, average peak velocity (18.8 (5.2) cm/s) and calculated coronary blood flow (23.8 (10.7) ml/min) were not altered by glibenclamide (18.3 (5.2) cm/s and 22.8 (10.4) ml/min, respectively). In post-stenotic arteries, baseline average peak velocity was 13.3 (4.9) ml/min and coronary blood flow was 9.1 (3.0) ml/min, without significant change after glibenclamide (13.3 (5.2) cm/s, 9.0 (3.2) ml/min). CONCLUSIONS: Glibenclamide, 0.05 mg/kg intravenously, is effective in increasing serum insulin, suggesting a K(ATP) channel blocking effect in pancreatic beta cells. It does not compromise coronary blood flow and vasodilatation in response to adenosine and papaverine in post-stenotic and angiographically normal coronary arteries at rest.

Three-year follow-up after rotational atherectomy for the treatment of diffuse in-stent restenosis: predictors of major adverse cardiac events.

Restenosis remains the major limitation of coronary stent implantation, especially in diffuse forms of in-stent restenosis. In this study, rotablation (RA) with adjunct angioplasty of in-stent restenosis was performed in 84 patients. Clinical follow-up and control angiography were obtained 6-month postprocedure. The rate of recurrent restenosis after rotablation for in-stent restenosis at 6-month angiographic follow-up was 45%, resulting in a rate of major adverse cardiac events of 35%. At 3-year follow-up, the cumulative event-free survival rate was 57% for the entire population. The only predictor of MACE at 3-year clinical follow-up by multivariate logistic regression analysis was in-stent lesion length. RA for the treatment of diffuse in-stent restenosis is thereby characterized by high procedural success rates and recurrent angiographic restenosis in 45% of patients with diffuse lesions. Major adverse cardiac events occur most likely within the first 6 months postprocedure. Three years after rotablation of in-stent restenosis, 43% of patients had experienced at least one major adverse cardiac event. Cathet Cardiovasc Intervent 2001;53:334-340.

[Current diagnosis and therapy in heart valve diseases]. / Aktuelle Diagnostik und Therapie von Herzklappenerkrankungen.

We present a survey of the current standard in diagnosis and therapy of the most frequent heart valve lesions. During the last 50 years there has been a dramatic shift concerning the etiology of valve lesions with a rise of the age-dependent degenerative towards rheumatic valve diseases. The aim of the diagnostic evaluation of valve lesions is primarily the clinical and hemodynamic grading of the severity of the valve disease, the recognition of relevant coexisting cardiac and extracardiac diseases and furthermore, an optimal timing of surgery in close correlation with the cardiac surgeons.

[Current standard in diagnosis and therapy of heart valve lesions]. / Aktuelle Diagnostik und Therapie von Herzklappenerkrankungen.

We present a survey of the current standard in diagnosis and therapy of the most frequent heart valve lesions. During the last 50 years there has been a dramatic shift concerning the etiology of valve lesions with a rise of the agedependent degenerative towards rheumatic valve diseases. The aim of the diagnostic evaluation of valve lesions is primarily the clinical and hemodynamic grading of the severity of the valve disease, the recognition of relevant coexisting cardiac and extracardiac diseases and furthermore, an optimal timing of surgery in close correlation with the cardiac surgeons.

Total occlusion trial with angioplasty by using laser guidewire. The TOTAL trial.

AIMS: A randomized trial was performed to assess the safety and efficacy of a laser guidewire, in the treatment of chronic coronary occlusions. METHODS AND RESULTS: In 18 European centres, 303 patients with a chronic coronary occlusion were randomized to treatment with either the laser guidewire (n=144) or conventional guidewires (mechanical guidewire, n=159). The primary end-point of the study was treatment success, defined as reaching the true lumen distal to the occlusion by the allocated wire within 30 min of fluoroscopic time: laser guidewire vs mechanical guidewire; 52.8% (n=76) vs 47.2% (n=75), P=0.33. Serious adverse events following the initial guidewire attempt were 0% (laser guidewire) and 0.6% (mechanical guidewire), respectively. Angioplasty (performed following successful guidewire crossing) was successful in 179 patients (91%, laser guidewire n=79, mechanical guidewire n=100), followed by stent implantation in 149 (79%). At the 6-month angiographic follow-up, the difference in binary restenosis rate (laser guidewire vs mechanical guidewire; 45.5% vs 38.3 %, P=0.72) or reocclusion rate (25.8% vs 16.1%, P=0.15) did not reach statistical significance. At 1, 6 and 12 months, angina and event-free survival were 69%, 35% and 24% (laser guidewire) vs 74%, 40% and 31% (mechanical guidewire). CONCLUSION: Although laser guidewire technology was safe, the increase in crossing success did not reach statistical significance.

[The symptomatic patient with pathologic coronary angiogram. "evidence-based" or "best-evidence medicine" in the interventional cardiology]. / Der symptomatische Patient mit pathologischem, interventionsbedürftigem Koronarogramm. "Evidence-based" oder "Best-Evidence Medicine" in der interventionellen Kardiologie.

Ischemic heart disease is the most frequent cause of death in industrialized countries. This is a result of persistent risk factors and aging of the population. Medical progress with application of conservative, surgical or interventional strategies indeed reduced the morbidity and mortality of arteriosclerotic diseases, but markedly increased the medical care costs. The result is a discussion about the optimal use of the different therapeutic measures under consideration of the evidence based medicine. This article reviews several recently published clinical trials and discusses, which patient with symptomatic coronary artery disease should undergo a conservative strategy, percutaneous or surgical revascularization.

Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging.

OBJECTIVE: To assess long term results of coronary stent implantation in patients with symptomatic myocardial bridging. METHODS: Intracoronary stent implantation was performed within the intramural course of the left anterior descending coronary artery in 11 patients with objective signs of myocardial ischaemia and absence of other cardiac disorders. All had myocardial bridging of the central portion of the left anterior descending coronary artery. Quantitative coronary angiography was performed before and after stent deployment, and again at seven weeks and six months. Clinical evaluation was done at two years. RESULTS: After stent deployment, quantitative coronary angiography showed absence of systolic compression along the left anterior descending coronary artery; the minimum luminal diameter (mean (SD)) increased from 0.6 (0.3) mm before stent implantation to 1.9 (0.3) mm after implantation (p < 0. 05). Intravascular ultrasound showed an increase in cross sectional area from 3.3 (1.3) mm(2) at baseline to 6.8 (0.9) mm(2) (p < 0.005) after stent deployment. Coronary flow reserve was normalised from 2. 6 (0.5) at baseline to 4.0 (0.5) (p < 0.005) after stent implantation. At seven weeks, quantitative coronary angiography showed mild to moderate or severe in-stent stenosis in five of the 11 patients; four of these underwent repeat target vessel revascularisation (percutaneous transluminal coronary angioplasty in two; coronary artery bypass grafting in two). At six months, all patients (n = 9) showed good angiographic results, including those who had target vessel revascularisation. On clinical evaluation at two years, all patients (including those with target vessel revascularisation) remained free of angina and cardiac events. CONCLUSIONS: Intracoronary stent implantation prevents external compression of bridged coronary artery segments, with increase in luminal diameter and alleviation of symptoms. The incidence of in-stent stenosis requiring target vessel revascularisation (36%) is comparable with that of lesions of 25 mm length in coronary artery disease. The symptom free and event free two year follow up data suggest that stent implantation is a useful way of treating symptomatic patients with myocardial bridges.