Midterm outcomes of LAA occlusion with the AMPLATZER Cardiac Plug and AMPLATZER Amulet devices in a high-risk cohort.

LAA occlusion has become a favourable option in patients with atrial fibrillation not eligible for oral anticoagulation therapy. Proof of effectiveness of LAA closure devices in a midterm follow-up period. This retrospective single-center cohort study analysed outcome in patients treated with AMPLATZER Cardiac Plug or AMPLATZER Amulet device. A standardized follow-up by phone call focusing on data of death, stroke and bleeding events was performed. Routine antiplatelet strategy was DAPT for 3 months post procedural. 212 patients (mean age 77 ± 6 years) were included. Follow up was performed in 197 (93%) patients. Patients were at high risk for thromboembolic or bleeding events (prior stroke/TIA 29%; prior bleeding 54%. Overall, there was a mean follow-up period of 1244.2 days (± 756.7) and a total of 674 patient years. We observed 25 events later than day 8 post procedure. We were able to demonstrate a high effectiveness of the AMPLATZER Cardiac Plug/AMPLATZER Amulet devices regarding the prevention of stroke and bleedings in a high-risk real-world cohort during a midterm follow-up period. Overall, we observed remarkably lower rates of stroke and bleedings as predicted with CHA2DS2-VASc and HASBLED scores.

Acute and Long-Term Hemodynamic Effects of MitraClip Implantation on a Preexisting Secondary Right Heart Failure.

Positive results of MitraClip in terms of improvement in clinical and left ventricular parameters have been described in detail. However, long-term effects on secondary pulmonary hypertension were not investigated in a larger patient cohort to date. 70 patients with severe mitral regurgitation, additional pulmonary hypertension, and right heart failure as a result of left heart disease were treated in the heart centers Hamburg and Göttingen. Immediately after successful MitraClip implantation, a reduction of the RVOT diameter from 3.52 cm to 3.44 cm was observed reaching a statistically significant value of 3.39 cm after 12 months. In contrast, there was a significant reduction in the velocity of the tricuspid regurgitation (TR) from 4.17 m/s to 3.11 m/s, the gradient of the TR from 48.5 mmHg to 39.3 mmHg, and the systolic pulmonary artery pressure (PAPsyst) from 58.6 mmHg to 50.0 mmHg. This decline continued in the following months (Vmax TR 3.09 m/s, peak TR 38.6 mmHg, and PAPsyst 47.4 mmHg). The tricuspid annular plane systolic excursion (TAPSE) increased from 16.5 mm to 18.9 mm after 12 months. MitraClip implantation improves pulmonary artery pressure, tricuspid regurgitation, and TAPSE after 12 months. At the same time, there is a decrease in the RVOT diameter without significant changes in other right ventricular and right atrial dimensions.

MitraClip® and Amplatzer® cardiac plug implantation in a single procedure: A reasonable approach?

BACKGROUND: Percutaneous mitral valve repair using MitraClip® (MC) is a well-established method for a subset of patients with severe mitral regurgitation (MR) and high risk for surgical intervention. Amplatzer® Cardiac Plug (ACP) occludes left atrial appendage and allows the discontinuation of oral anticoagulation and prevention of thromboembolic stroke. Due to the need for femoral and transseptal access in both procedures, a single approach could lead to minor risk of further complications and shorter cumulative intervention time. METHODS: We systematically analysed all four patients who underwent a combined procedure with MC and ACP in our heart-centre. All procedures were performed under fluoroscopic as well as echocardiographic guidance, and follow-up controls in a midterm period were carried out. RESULTS: In all patients (2 male/female; age 73-88years), MC (1-2 Clips) and ACP (size 18-28mm) were successfully implanted in one procedure (mean total time: 114±17min). At least moderate MR was achieved and two patients had no complications and therefore were discharged early. In a third patient, a dislocation of ACP occurred 2h after the implantation. The oldest patient developed a respiratory insufficiency due to cardiac decompensation and further complications. CONCLUSION: A combination of MC and ACP in a single procedure was feasible in this first case series of patients without a significant extension of procedure time. However, it might be important to select patients carefully. The location of optimal transseptal puncture may be challenging in regard to ACP placement, even in experienced hands and subsequent complications can occur.

[Catheter-based mitral valve repair by MitraClip implantation : Development, studies, and use in clinical practice]. / Kathetergestützte Mitralklappenreparatur mittels MitraClip : Entwicklung, Studienlage und Einsatz im Klinikalltag.

The percutaneous edge-to-edge mitral valve repair with MitraClip® is evolving as a potential alternative to conventional surgery in high-risk patients with significant mitral regurgitation (MR). The randomized controlled EVEREST II-trial which compared percutaneous repair versus surgery in operable patients with symptomatic severe MR demonstrated superior safety of MitraClip® implantation but better MR reduction after surgery at 12 months. However, large registries on MitraClip® therapy showed that real-world MitraClip® patients differ significantly from the EVEREST II-cohort: they are older, in more advanced stages of heart failure, present predominantly with secondary MR, and exhibit a higher burden of comorbidities. For these patients, registry data confirm a low incidence of peri-interventional complications and a significant improvement of heart failure symptoms and quality of life measures after MitraClip® implantation. The ongoing RESHAPE trial with randomization of MitraClip® implantation against optimal medical therapy investigates a possible survival benefit after MitraClip® in patients with secondary MR.

Size and shape of the lunate surface in different types of pincer impingement: theoretical implications for surgical therapy.

OBJECTIVE: Acetabular rim trimming is indicated in pincer hips with an oversized lunate surface but could result in a critically decreased size of the lunate surface in pincer hips with acetabular malorientation. There is a lack of detailed three-dimensional anatomy of lunate surface in pincer hips. Therefore, we questioned how does (1) size and (2) shape of the lunate surface differ among hips with different types of pincer impingement? METHOD: We retrospectively compared size and shape of the lunate surface between acetabular retroversion (48 hips), deep acetabulum (34 hips), protrusio acetabuli (seven hips), normal acetabuli (30 hips), and hip dysplasia (45 hips). Using magnetic resonance imaging (MRI) arthrography with radial slices we measured size in percentage of the femoral head coverage and shape using the outer (inner) center-edge angles and width of lunate surface. RESULTS: Hips with retroversion had a decreased size and deep hips had normal size of the lunate surface. Both had a normal shape of the outer acetabular rim. Protrusio hips had an increased size and a prominent outer acetabular rim. In all three types of pincer hips the acetabular fossa was increased. CONCLUSION: Size and shape of the lunate surface differs substantially among different types of pincer impingement. In contrast to hips with protrusio acetabuli, retroverted and deep hips do not have an increased size of the lunate surface. Acetabular rim trimming in retroverted and deep hips should be performed with caution. Based on our results, acetabular reorientation would theoretically be the treatment of choice in retroverted hips.

[Free-floating right heart thrombi in pulmonary embolism: therapeutic options and differential diagnosis]. / Flottierende rechtskardiale Transit-Thromben bei akuter Lungenembolie: Therapeutische Optionen und Differenzialdiagnosen

BACKGROUND: There is little published evidence on the treatment of mobile masses in the right heart. We report the clinical courses of three consecutive patients presenting with acute pulmonary embolism and mobile masses in the right heart. HISTORY AND ADMISSION FINDINGS: Three women, aged 75, 72 and 52 years, were hospitalized within three months because of dyspnea and suspected pulmonary embolism. INVESTIGATIONS: Transthoracic echocardiography revealed right ventricular dysfunction and highly mobile masses, which were considered as in-transit right heart thrombi in all cases. TREATMENT AND COURSE: All patients received immediate thrombolytic therapy (alteplase). No bleeding complications occurred. Thrombolysis was successful in the first two cases. However, the mass in the right ventricle did not disappear after thrombolysis in the third case and was removed surgically later on. The definite histological diagnosis was a myxoma of the right ventricle. CONCLUSION: According to literature, in-transit right heart thrombi are a potentially life-threatening complication of pulmonary embolism even in stable patients. Immediate thrombolysis is a valid therapeutic option and was successfully performed in 2 of our 3 patients. However, as case 3 suggests, differential diagnoses concerning mobile masses in the right heart, i. e. cardiac myxoma, should be taken into account and excluded by thoracic computed tomography .

[Diabetes increases short- and long-term mortality after transcatheter aortic valve implantation (TAVI)]. / Diabetes mellitus erhöht die eingriffsbedingte und die langfristige Mortalität nach kathetergestützter Aortenklappenimplantation.

BACKGROUND AND AIM: Long-term mortality after transcatheter aortic valve implantation (TAVI) in elderly patients with abundant comorbidities is considerable. We aimed to determine the impact of diabetes on short- and long-term mortality after TAVI. METHODS: Our study includes 300 consecutive patients (mean age, 82 ± 5 years) who underwent TAVI (158 transapical, 142 transfemoral procedures). All patients were followed by regular telephone contacts. 36% suffered from diabetes. RESULTS: Diabetes could be identified as significant predictor of short- and long-term mortality after TAVI. In diabetic patients, 30-day-mortality was 2,5 fold elevated (18.3% vs. 7.3%, p = 0.004). Furthermore, they were at significantly higher risk of peri-interventional stroke (p = 0.04), stage 3 acute kidney injury (p = 0.003), and prolonged ventilation (p = 0.01). Even after successful TAVI and discharge from hospital, long-term mortality was significantly elevated in diabetic patients (56% vs. 30%, p < 0.0001). Of note, 25% of diabetic vs. only 8% of non-diabetic patients died from cardiac causes during follow-up, suggesting that TAVI is not able to reduce cardiac-related mortality risk in diabetic patients to the same extent as in non-diabetics. CONCLUSION: Diabetes represents a powerful predictor of adverse early and late outcome after TAVI. These findings should be incorporated into the assessment of the risk-to-benefit ratio of TAVI in diabetic patients.

Heart-type fatty acid-binding protein for risk assessment of chronic thromboembolic pulmonary hypertension.

Heart-type fatty acid-binding protein (H-FABP) is a reliable marker of myocardial injury and was recently identified as a predictor of outcome in acute pulmonary embolism. The aim of the present study was to investigate the prognostic value of H-FABP in chronic thromboembolic pulmonary hypertension (CTEPH). In total, 93 consecutive patients with CTEPH were studied. During long-term follow-up (median duration 1,260 days, interquartile range (IQR) 708-2,460 days), 46 (49%) patients had an adverse outcome, defined as CTEPH-related death, lung transplantation or persistent pulmonary hypertension after pulmonary endarterectomy (PEA). Baseline H-FABP levels in plasma ranged from 0.69-24.3 ng x mL(-1) (median (IQR) 3.41 (2.28-4.86) ng x mL(-1)). Cox regression analysis revealed a hazard ratio of 1.10 (95% confidence interval 1.04-1.18) for each increase of H-FABP by 1 ng x mL(-1), and continuous elevations of H-FABP emerged as an independent predictor of adverse outcome by multivariable analysis. PEA was performed in 52 patients and favourably affected the long-term outcome. Kaplan-Meier analysis revealed that patients with baseline H-FABP concentrations >2.7 ng x mL(-1), the median value of the biomarker in the surgically treated population, had a lower probability of event-free survival after PEA. Heart-type fatty acid-binding protein is a promising novel biomarker for risk stratification of patients with chronic thromboembolic pulmonary hypertension.

[Adhesive substances in medicine--history, present status and perspectives]. / Adhezivní hmoty v medicíne--historie, soucasnost a perspektivy.

In the introduction to this study, present state of the progress of tissue adhesives and their use in medicine is discussed. Synthetic adhesives and the fibrin system are described. The advantages and disadvantages of both types of adhesive are compared. The bioadhesive systems used in medicine must meet certain requirements necessary for their application. The composition and preparation of the fibrin adhesives are analyzed in detail. Their effect on the regeneration of tissue cells and the level of histotoxicity are very important. The characteristics of the fibrin adhesive system result from its physiological origin. The filling of the wound with these adhesives improves the natural processes of healing.

[The Tissucol Kit and the USOL fibrin preparation--comparison of qualitative and quantitative parameters]. / Tissucol Kit a fibrinový preparát USOL--srovnání kvalitativních a kvantitativních parametru.

The tissue adhesives used in medicine have to achieve certain requirements necessary for their application. The composition and preparation of the fibrin adhesives are analyzed in details. Our experience with our own modified application system is described. In the experimental section, the quantitative indicators of the foreign product Tissucol Kit are compared with samples of the fibrin product developed by USOL Olomouc and manufactured from the locally produced components. The samples of the USOL adhesive were similar to Tissucol in their composition and concentration.

Law enforcement and crisis intervention services: a critical relationship.

Law-enforcement officers tend to look at traditional mental health services as being of little help to them in dealing with persons they encounter experiencing emotional emergencies. They are frequently skeptical that emergency mental health programs offer more than they deliver. Because of their traditional base as the primary, and frequently only, available emergency "field" service in a community, a mental health emergency program must have a cooperative working relationship with law enforcement to serve a community successfully. This paper describes the development and maintenance of such a relationship, designed to increase the police case-finding potential.