Showing papers by "Heart and Diabetes Center North Rhine-Westphalia published in 2010"

Scanning electron microscopic analysis of different drug eluting stents after failed implantation: From nearly undamaged to major damaged polymers†

Abstract: Background: Implantation of drug eluting stents (DES) in tortuous and/or calcified vessels is much more demanding compared with implantation of bare metal stents (BMS) due to their larger diameters. It is unknown whether drug eluting stent coatings get damaged while crossing these lesions. Methods: In 42 patients (34 male, 68.1 ± 10 years) with 45 calcified lesions (15.9 mm ± 7.9 mm), DES could not be implanted, even after predilatation. Diabetes was present in 19 patients (45 %). Sixty-one stents were used; 19 Cypher select™, 18 Taxus Liberte™, 10 CoStar™, 5 Endeavor RX™, 4 Xience V™. 3 Janus Carbostent™, 1 Yukon Choice S™, and 1 Axxion™ DES. The entire accessible surface area of these stents, in either the unexpanded and expanded state, were examined with an environmental scanning electron microscope (XL30 ESEM, Philips) to evaluate polymer or surface damage. Results: The polymers of Taxus Liberte, Cypher Select, Xience V, CoStar, and Janus DES were only slightly damaged (less than 3% of surface area), whereas the Endeavor RX Stents showed up to 20% damaged surface area. In DES without a polymer (Yukon and Axxion), it could be shown that most of the stent surface (up to 40%) were without any layer of drug. Conclusion: Placement of drug eluting stents in tortuous vessels and/or calcified lesions could cause major surface damage by scratching and scraping of the polymer or drug by the arterial wall, even before implantation. There were remarkable differences among the stents examined, only minor damage with the Cypher, Taxus Costar, Janus, and Xience V, whereas the Endeavor, the Yukon, and the Janus DES showed large areas of surface injury. © 2009 Wiley-Liss, Inc.

Nonclassical Vitamin D Actions

Abstract: It is becoming increasingly clear that vitamin D has a broad range of actions in the human body. Besides its well-known effects on calcium/phosphate homeostasis, vitamin D influences muscle function, cardiovascular homeostasis, nervous function, and the immune response. Vitamin D deficiency/insufficiency has been associated with muscle weakness and a high incidence of various chronic diseases such as cardiovascular disease, cancer, multiple sclerosis, and type 1 and 2 diabetes. Most importantly, low vitamin D status has been found to be an independent predictor of all-cause mortality. Several recent randomized controlled trials support the assumption that vitamin D can improve muscle strength, glucose homeostasis, and cardiovascular risk markers. In addition, vitamin D may reduce cancer incidence and elevated blood pressure. Since the prevalence of vitamin D deficiency/insufficiency is high throughout the world, there is a need to improve vitamin D status in the general adult population. However, the currently recommended daily vitamin D intake of 5-15 µg is too low to achieve an adequate vitamin D status in individuals with only modest skin synthesis. Thus, there is a need to recommend a vitamin D intake that is effective for achieving adequate circulating 25-hydroxyvitamin D concentrations (>75 nmol/L).

Five-year long-term clinical follow-up of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo coronary artery lesions: the SPIRIT FIRST trial.

Abstract: Background: Drug-eluting stents have shown to be superior over bare metal stents in clinical and angiographic outcomes after percutaneous treatment of coronary artery stenosis. However, long-term follow-up data are scarce and only available for sirolimus- and paclitaxel-eluting stents. Aim: To assess the feasibility and performance of the XIENCE V everolimus-eluting stent (EES) versus an identical bare metal stent after a 5-year follow-up period. Methods: SPIRIT FIRST was a First in Man, multicentre, prospective, single-blind, clinical trial, randomizing 60 patients with a single de novo coronary artery lesion in a ratio of 1:1 to either an everolimus eluting or a bare metal control stent. Results: At 5-year clinical follow-up, data were available in 89% and 86% of patients in the everolimus and control arm, respectively. In the everolimus arm, no additional death, myocardial infarction, clinically driven target lesion revascularization (TLR), or clinically driven target vessel revascularization (TVR) events were observed between 1- and 5-year follow-up. The 5-year hierarchical major adverse cardiac events (MACE) and target vessel failure (TVF) rates for the everolimus arm were 16.7% (4/24) for both endpoints. In the control group, no additional cardiac death, myocardial infarction, or clinically driven TLR events were observed between 2- and 5-year follow-up. No additional clinically driven TVR events were observed between 3- and 5-year follow-up. The 5-year hierarchical MACE and TVF rates for the control arm were 28.0% (7/25) and 36.0% (9/25), respectively. No stent thromboses were observed in either the everolimus arm or the control arm up to 5 years. Conclusion: The favorable 5-year long term clinical outcome of the EES is consistent with the results from other studies of the EES with shorter follow-up. (C) 2010 Wiley-Liss, Inc

DuraHeart™ magnetically levitated centrifugal left ventricular assist system for advanced heart failure patients

Abstract: The implantable left ventricular assist system (LVAS) using pulsatile pump technology has become an established therapeutic option for advanced heart failure patients. However, there have been technological limitations in some older designs, including a high incidence of infection and mechanical failures associated with moving parts, and the large size of both implantable pump and percutaneous cable. A smaller rotary blood pump emerged as a possible alternative to a large pulsatile pump to overcome some of these limitations. The technological advancement that defines the third-generation LVAS was the elimination of all mechanical contacts between the impeller and the drive mechanism. The DuraHeart TM LVAS is the world's first third-generation implantable LVAS to obtain market approval (CE-mark), which combines a centrifugal pump and active magnetic levitation. The initial clinical experience with the DuraHeart LVAS in Europe demonstrated that it provided significantly improved survival (85% at 6 months and 79% at 1 year), reduced adverse event rates and long-term device reliability (freedom from device replacement at 2 years: 96 ± 3%) over pulsatile LVAS.

How to diagnose cardiac amyloidosis early: impact of ECG, tissue Doppler echocardiography, and myocardial biopsy.

Abstract: Aims. To detect cardiac amyloidosis (CA) earlier, it is inevitable to improve diagnostic strategies.Methods and results. The impact of ECG, echocardiography including tissue Doppler imaging (TDI) and strain, and myocardial biopsies was evaluated in 30 patients (63% (n = 19) men, mean age 66 ± 8 years, NYHA 3.0 ± 0.5, 73% with prior myocardial decompensation), in whom we proved CA. Amyloid was confirmed by apple-green birefringence under polarised light, and the causing protein by immunohistochemical examinations. Genetic analyses excluded familial CA. All patients (AL-lambda (n = 22), AL-kappa (n = 3), senile amyloidosis (n = 5)) had echocardiographic signs of restrictive cardiomyopathy (RCM), typical TDI and strain parameters (E'septal; E′ lateral 8; S' ≤9 cm/s; global longitudinal strain (GLS) −7.9 ± 3.8%). Pericardial effusions were present in 63% of patients. ECGs were suspicious in many patients: 19 (63%) had low-voltage, 23 (77%) reduced R waves in V1–V4, and 57% both. Abnormalities...

Sleep apnea is common in patients with coronary artery disease.

Abstract: Sleep-disordered breathing (SDB) has a prognostic impact in patients with cardiac diseases We included 257 patients with preserved left ventricular function and angiographically proven coronary artery disease (CAD) All patients underwent cardiorespiratory polygraphy In 251 patients high-sensitive C-reactive protein and fibrinogen were measured SDB was documented in 188 patients (apnea-hypopnea-index [AHI] 164± 19/h): 58 patients presented central sleep apnea (CSA) and 130 patients obstructive sleep apnea (OSA) All patients (73%) with SDB had higher blood fibrinogen levels than those without SDB (p = 001) We found 197 patients with CRP-values below the cut-off of 05 mg/dl (group 1) and 54 patients with no active infection but CRP>05 mg/dl (group 2) Severity of SDB was significantly higher in group 2 (p = 001) SDB has a high prevalence in CAD patients and seems to be associated with chronic inflammation, which may be linked to CAD progression and/or acute coronary events

EuroSCORE-predicted mortality and surgical judgment for interventional aortic valve replacement.

Abstract: BACKGROUND AND AIM OF THE STUDY Transcatheter aortic valve implantation (TAVI) is used as an alternative to conventional surgery in high-risk patients. The EuroSCORE quantifies the risk, and patients are selected for this procedure if their predicted mortality is high. The study aim was to evaluate the risk discrimination and calibration of the EuroSCORE, as well as the surgical judgment that is used when selecting the aortic valve replacement (AVR) approach. METHODS Between 2003 and 2006, a total of 2757 patients underwent isolated, open AVR. The EuroSCORE was compared to the observed in-hospital mortality. A survey among surgeons assessed the relevance of patient-specific factors towards the approach of TAVI versus open AVR. RESULTS Survivors of AVR had a lower additive EuroSCORE than non-survivors (7.2 +/- 3.34 versus 12.0 +/- 3.34; p < 0.001). The EuroSCORE demonstrated reasonable risk stratification (c-statistic 0.843, p < 0.001). However, none of the 67 non-survivors was correctly predicted (Hosmer-Lemeshow test; p < 0.001), and most patients with a high EuroSCORE survived AVR. The actual mortality was 2.8% as compared to a EuroSCORE-predicted mortality of 12.5 +/- 14.2% (p < 0.001). This poor calibration was worse with higher EuroSCOREs (Cusum test; p < 0.001). Surgeons identified a porcelain aorta as the only factor that warranted TAVI. Most EuroSCORE variables had either no relevance for treatment selection, or prompted open AVR. CONCLUSION Patient selection for TAVI cannot be based on the EuroSCORE, because it lacks discrimination and center-specific calibration. Thus, individual, surgical judgment that weighs institutional expertise for high-risk patients against a possible reduction of mortality by using interventional techniques, is recommended.

Thrombosis of the ascending aorta during mechanical circulatory support in a patient with cardiogenic shock.

Abstract: Cardiogenic shock after percutaneous coronary intervention (PCI) is a life-threatening complication and is most often related to abrupt vessel closure. We present the case of a patient who developed cardiogenic shock after PCI and was supported with intra-aortic balloon counterpulsation and the Levitronix CentriMag short-term mechanical circulatory support. He was evaluated for implantation of a ventricular assist device as bridge-to-transplantation. Preoperative transesophageal echocardiography revealed a massive thrombus of the aortic root and ascending aorta despite optimal anticoagulation regimen. The patient succumbed due to multiorgan failure.

Successful interventional treatment of a retrosternal pseudoaneurysm of the ascending aorta with an Amplatzer Vascular Plug II.

Abstract: Pseudoaneurysm of the aorta is a rare, but potentially dangerous complication after cardiac surgery, trauma or infective aortitis. Potential fatal risk of rupture with severe hemorrhage exists, so that treatment is necessary. Surgical management carries a high morbidity and mortality rate. Using an endovascular transcatheter method seems to be a promising option for treatment of aortic pseudoaneurysms. We report a case of ascending aortic pseudoaneurysm, which was diagnosed 11 years after cardiac surgery and treated successfully by implantation of an Amplatzer Vascular Plug II.

The Paclitaxel-Eluting Coroflex™ Stent Study II (PECOPS II) Acute and 6-Month Clinical and Angiographic Follow-Up, 1-Year Clinical Follow-Up

Abstract: Background and Objectives: Paclitaxel-coated stents have proven their efficacy for reducing restenosis in de novo coronary artery lesions and in-stent restenoses with superiority compared to bare metal stents. This study was performed to evaluate the procedural and 1 year results of the Paclitaxel-eluting Coroflex™ Please stent in coronary artery lesions. Methods: One-hundred and twenty-nine patients (66.2 ± 8.2 years, 31.0% diabetics, 20.2% unstable angina, 41.8% multivessel disease) were enrolled per protocol for elective single stent deployment into native de novo or post-PTCA restenotic coronary lesions.The mean reference diameter was 2.84 ± 0.43 mm, the lesion length 12.51 ± 4.6 mm, and the minimal lumen diameter 0.75 ± 0.29 mm. Follow-up was performed clinically in 129/129 (100%) after 6 and 12 months and angiographically in 120/129 (93%) patients after 6 months. Results: The success rates of the procedure and deployment were 100% and 95.3%, respectively. The in-stent late loss and the late-loss index were 0.27 ± 0.59 mm and 0.17 ± 0.40 resulting in binary in-stent restenoses in 16/120 (13.3%) subjects and in-segment restenoses in 20/120 (16.7%) subjects. Major adverse cardiac events occurred in 23/129 (17.8%) during the first 6 months of follow-up with 3/129 (2.3%) myocardial infarctions, 1/129 (0.8%) secondary to stent thrombosis. From 6 to 12 months, 2/129 (1.6%) nonlesion related PCI were performed. Conclusion: The data of the Paclitaxel-eluting Coroflex™ Please stent evaluated in PECOPS II are within the range of the other currently available Paclitaxel-eluting stent. (J Interven Cardiol 2010;23:160-166)

Reduction in ECG abnormalities and improvement of regional left ventricular function in a patient with Fabry's disease during enzyme-replacement therapy.

Abstract: A 65-year-old German woman was admitted to our hospital with signs and symptoms of an acute coronary syndrome (NSTEMI). On admission, she reported progressive cervical and chest pain, since a few hours. On physical examination, there was a non-specific cardiac murmur with punctum maximum at Erb0s point. Lung sounds were normal, and blood pressure was 115/70 mmHg. The following laboratory data were obtained: creatine kinase of 282 U/L (reference level \171 U/L), troponin I 4.5 lg/L (reference level \0.04 lg/L), lactate dehydrogenase of 250 U/L (reference level \248 U/L), creatinine of 0.82 mg/dL (reference level 0.7–1.2 mg/dL) and C-reactive protein of 0.29 mg/dL (reference level \0.5 mg/dL). The ECG demonstrated repolarization abnormalities in leads I, II, III, aVF and V4-V6 (Fig. 1a). Cardiac catheterization excluded a significant macroangiopathy. A transthoracic echocardiogram was consistent with hypertrophic cardiomyopathy of the apical type without significant LV outflow obstruction (Fig. 2a) prompting routine screening to exclude secondary origin of LVH. A decreased a-galactosidase A activity was found and triggered further molecular genetic workup. A Fabry-specific mutation C.559.A[G (M187V) in the a-galactosidase gene was identified. In addition to symptomatic medical treatment, and in cooperation with a regional center for Fabry’s disease, the patient received continuous enzymereplacement therapy with Agalsidase-b [1]. After 1 year, the clinical status of the patient was stable. Both regression of the ST segment abnormalities (Fig. 1b) on ECG, and improvement of regional LV function (Fig. 2b) by speckle tracking echocardiography was documented [2, 3]. This report illustrates the potential of a causal therapy in patients with cardiac manifestations of Fabry’s disease.

Successful correction of a total anomalous venous connection in a 63-year-old male--case report and review of the literature.

Abstract: Total anomalous pulmonary venous connection is a rare variant of cyanotic congenital heart disease and usually requires surgical correction within the first few months of life. We report midterm results of a 63-year-old male with intracardiac total anomalous venous return into the coronary sinus who presented with congestive predominantly right heart failure and underwent corrective surgery with unroofing of the coronary sinus and patch closure of the secundum atrial septal defect.

Central Sleep Apnea in Patients due to Severe Aortic Stenosis

Abstract: History. We report about the course of central sleep apnea (CSA) in 3 patients (70.3 +/- 15.2 years) with severe aortic stenosis (AS) (AVA

Percutaneous balloon mitral valvulotomy and coexisting left atrial hemangioma: case report and long-term follow-up.

Abstract: Hemangiomas of the heart are extremely rare. The prognosis is quite variable, because this benign tumor may grow, involute, or stop growing; therefore, resection is usually the treatment of choice. In patients with tumors of the left atrium, percutaneous balloon mitral valvulotomy is generally contraindicated. Yet for patients with moderate-to-severe mitral valve stenosis, balloon valvulotomy is an established therapy. Herein, we present the case of a 73-year-old woman who was referred to our department in 1995 with severe mitral valve stenosis. Echocardiography showed a valve orifice area of 0.9 cm2, according to Gorlin's formula, and a mean pressure gradient of 11 mmHg. Surgical therapy was declined by the patient. There were no signs of coronary artery disease. The injection of contrast medium into the left coronary artery showed a hemangioma at the posterior wall of the left atrium. Magnetic resonance imaging and transesophageal echocardiography confirmed the diagnosis. Despite the increased risk posed by the hemangioma, we performed successful percutaneous balloon mitral valvulotomy with an Inoue balloon. We saw the patient in 2001, and again in 2008 when she was 86 years of age. She was in excellent condition, with no signs of relevant dyspnea. Magnetic resonance imaging showed the size of the hemangioma to be stable. By use of echocardiography, we were able to confirm a good long-term result of the balloon valvulotomy. In this patient, a nonsurgical approach was adequate because of the lack of growth of the hemangioma in the left atrium.