6 research outputs found
Cusp-overlap view reduces conduction disturbances and permanent pacemaker implantation after transcatheter aortic valve replacement even with balloon-expandable and mechanically-expandable heart valves
BackgroundConduction disturbances demanding permanent pacemaker implantation (PPI) remain a common complication after transcatheter aortic valve replacement (TAVR). Optimization of the implantation depth (ID) by introducing the cusp-overlap projection (COP) technique led to a reduced rate of PPI when self-expanding valves were used.ObjectivesThe aim of the present study was to determine if using the novel COP view is applicable for all types of TAVR prosthesis and results in a higher ID and reduced incidence of new conduction disturbances and PPI.MethodsIn this prospective case-control study 586 consecutive patients undergoing TAVR with either balloon-expandable Edwards SAPIEN S3 (n = 280; 47.8%), or mechanically expandable Boston LOTUS Edge heart valve prostheses (n = 306; 52.2%) were included. ID as well as rates of periprocedural PPI and left bundle branch block (LBBB) were compared between the conventional three-cusp coplanar (TCC) projection and the COP view for implantation.ResultsOf 586 patients, 282 (48.1%) underwent TAVR using COP, whereas in 304 patients (51.9%) the TCC view was applied. Using COP a significantly higher ID was achieved in Edwards SAPIEN S3 TAVR procedures (ID mean difference −1.0 mm, 95%−CI −1.9 to −0.1 mm; P = 0.029), whereas the final platform position did not differ significantly between both techniques when a Boston LOTUS Edge valve was used (ID mean difference −0.1 mm, 95%-CI −1.1 to +0.9 mm; P = 0.890). In Edwards SAPIEN S3 valves, higher ID was associated with a numerically lower post-procedural PPI incidence (4.9% vs. 7.3%; P = 0.464). Moreover, ID was significantly deeper in patients requiring PPI post TAVR compared to those without PPI [8.7 mm (6.8–10.6 mm) vs. 6.5 mm (6.1–7.0 mm); P = 0.005]. In Boston LOTUS Edge devices, COP view significantly decreased the incidence of LBBB post procedure (28.1% vs. 47.9%; P < 0.001), while PPI rates were similar in both groups (21.6% vs. 25.7%; P = 0.396).ConclusionThe present study demonstrates the safety, efficacy and reproducibility of the cusp-overlap view even in balloon-expandable and mechanically-expandable TAVR procedures. Application of COP leads to significantly less LBBB in repositionable Boston LOTUS Edge valves and a numerically lower PPI rate in Edwards SAPIEN S3 valves post TAVR compared to the standard TCC projection. The results should encourage to apply the COP view more widely in clinical practice
Drug-coated balloon: an effective alternative to stent strategy in small-vessel coronary artery disease—a meta-analysis
BackgroundSmall-vessel coronary artery disease (CAD) is frequently observed in coronary angiography and linked to a higher risk of lesion failure and restenosis. Currently, treatment of small vessels is not standardized while having drug-eluting stents (DES) or drug-coated balloons (DCBs) as possible strategies. We aimed to conduct a meta-analytic approach to assess the effectiveness of treatment strategies and outcomes for small-vessel CAD.MethodsComprehensive literature search was conducted using PubMed, Embase, MEDLINE, and Cochrane Library databases to identify studies reporting treatment strategies of small-vessel CAD with a reference diameter of ≤3.0 mm. Target lesion revascularization (TLR), target lesion thrombosis, all-cause death, myocardial infarction (MI), and major adverse cardiac events (MACE) were defined as clinical outcomes. Outcomes from single-arm and randomized studies based on measures by means of their corresponding 95% confidence intervals (CI) were compared using a meta-analytic approach. Statistical significance was assumed if CIs did not overlap.ResultsThirty-seven eligible studies with a total of 31,835 patients with small-vessel CAD were included in the present analysis. Among those, 28,147 patients were treated with DES (24 studies) and 3,299 patients with DCB (18 studies). Common baseline characteristics were equally distributed in the different studies. TLR rate was 4% in both treatment strategies [0.04; 95% CI 0.03–0.05 (DES) vs. 0.03–0.07 (DCB)]. MI occurred in 3% of patients receiving DES and in 2% treated with DCB [0.03 (0.02–0.04) vs. 0.02 (0.01–0.03)]. All-cause mortality was 3% in the DES group [0.03 (0.02–0.05)] compared with 1% in the DCB group [0.01 (0.00–0.03)]. Approximately 9% of patients with DES developed MACE vs. 4% of patients with DCB [0.09 (0.07–0.10) vs. 0.04 (0.02–0.08)]. Meta-regression analysis did not show a significant impact of reference vessel diameter on outcomes.ConclusionThis large meta-analytic approach demonstrates similar clinical and angiographic results between treatment strategies with DES and DCB in small-vessel CAD. Therefore, DES may be waived in small coronary arteries when PCI is performed with DCB
Die Bedeutung der N-Glykosylierung von T-Zell Populationen in der Experimentellen Autoimmunen Enzephalomyelitis
In Experimenten diverser Arbeitsgruppen zeigt sich eine Beeinflussbarkeit der Entstehung und des Verlaufs der EAE durch die Manipulation N-Glykosylierender Prozesse, weshalb wir anhand dieses Tiermodells für die MS systematisch FACS-Analysen der N-Oberflächenglykosylierung auf an der EAE-Entwicklung beteiligten Immunzelltypen aus Milz und Lymphknoten sowohl aus gesunden als auch aus immunisierten SJL-Mäusen untersuchten.
Wir konnten zeigen, dass die Intensität der N-Oberflächenglykosylierung auf den an der Pathogenese der EAE beteiligten Immunzellen in naiven Mäusen zelltypabhängig ist. Dabei unterscheiden sich sowohl die gängigen Gruppen wie T-Zellen, B-Zellen und dendritische Zellen als auch deren Subklassen wie etwa T-Helfer-Zellen oder CD4+- und CD4--dendritische Zellen im Ausmaß ihrer N-Oberflächenglykosylierung. Das Ausmaß dieser bestimmt dabei nicht nur den Zellphänotyp sondern auch die Zellfunktion. Über eine Inhibition der intrazellulären N-Glykosylierung mittels Kifunensin gelingt eine massive Reduktion der N-Oberflächenglykosilierung. In unseren Versuchen zeigten regulatorische T-Zellen mit auf diese Weise gehemmter N-Glykosylierung eine geringere inhibitorische Wirkung auf die T-Effektorzellproliferation als regulatorische T-Zellen mit unbeeinflusster N-Glykosylierung.
Immunzellen desselben Subtyps unterscheiden sich je nach Lokalisation in ihrer N-Oberflächenglykosylierung. Im Lymphknoten ist die N-Oberflächenglykosylierung in der Regel deutlich geringer ausgeprägt als auf Immunzellen aus der Milz. 8 Tage nach Immunisierung mit PLP 139-151-Peptid kommt es bei Immunzellen aus den das Injektionsareal drainierenden Lymphknoten zu einer hochsignifikanten Zunahme der N-Oberflächenglykosylierung auf den meisten Immunzellen, deren Ausprägung zelltypabhängig ausfällt. In der Milz zeigen zu diesem Zeitpunkt nur wenige Immunzelltypen eine Reaktion in Form einer Änderung der N-Oberflächenglykosylierung. Die zwischen Immunzellen aus Milz und Lymphknoten aus naiven Tieren bestehenden Unterschiede in der N-Oberflächenglykosylierung sind 8 Tage nach Immunisierung nur noch für wenige Zelltypen nachweisbar.
Die Ergebnisse unserer Experimente unterstreichen die Bedeutung weiterer Untersuchungen N-Glykosylierender Prozesse und deren Auswirkung auf komplexe Sachverhalte wie die Entstehung der Autoinflammation im Rahmen der MS. Dabei erscheint die EAE als vielversprechendes Modell. Interessant sind diese Prozesse für weitere Forschungsarbeiten vor allem durch ihre multifaktorielle Beinflussbarkeit z.B. durch Genetik und Umweltfaktoren. Viele Einzelprozesse und -faktoren und deren genaue Bedeutung sind jedoch nach wie vor unklar und erfordern weitere detaillierte Untersuchungen
Imaging Challenges in Patients with Severe Aortic Stenosis and Heart Failure: Did We Find a Way Out of the Labyrinth?
Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as “sine qua non” in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up
Outcome of Patients with Mixed Aortic Valve Disease Undergoing Transfemoral Aortic Valve Replacement
<p><b>Background:</b> Data on transfemoral aortic valve replacement (TAVR) in patients with mixed aortic valve disease (MAVD) compared with aortic stenosis (AS) are missing. The aims of this study were to assess feasibility of TAVR in MAVD and evaluate the impact on short- and long-term outcome. The primary endpoint was all-cause mortality or disabling stroke within 12 months.</p> <p><b>Methods:</b> Between 2014 and 2016, 734 patients were enrolled (clinicaltrials.gov NCT02162069), 665 had AS, 69 presented with MAVD. Mixed aortic valve disease was defined as coexistence of severe aortic stenosis and moderate to severe aortic regurgitation (AR).</p> <p><b>Results:</b> VARC-2 early safety endpoint at 30 days was 8.1% in isolated AS and 10.1% in MAVD (<i>p</i> = 0.57) with no significant differences in all-cause mortality (AS 1.8%, MAVD 4.3%, <i>p</i> = 0.16) and rate of disabling stroke (AS 1.7%, MAVD 1.4%, <i>p</i> = 0.89). There was no difference in residual aortic regurgitation between groups. The primary endpoint at 12 months was comparable (AS 18.3%, MAVD 19.9%, <i>p</i> = 0.87). Within 24 months (AS 26.9%, MAVD 19.9%, <i>p</i> = 0.10) there was no significant difference in all-cause mortality or disabling stroke. Rate of rehospitalization for congestive heart failure did not differ between groups. In multivariate analyses STS for mortality (<i>p</i> < 0.01) and atrial fibrillation (<i>p</i> = 0.02) were independent predictors for the primary endpoint at 12 months. In a propensity matched population outcomes were not different within 12 and 24 months.</p> <p><b>Conclusion:</b> TAVR in patients with MAVD is associated with a comparable 30 days, 12- and 24-month clinical outcome compared to patients undergoing TAVR for aortic stenosis.</p
Long-Term Mortality after Transcatheter Edge-to-Edge Mitral Valve Repair Significantly Decreased over the Last Decade: Comparison between Initial and Current Experience from the MiTra Ulm Registry
(1) Objective: We aimed to assess whether the candidate profile, the long-term outcomes and the predictors for long-term mortality after transcatheter edge-to-edge mitral valve repair (M-TEER) have changed over the last decade; (2) Methods: Long-term follow-up data (median time of 1202 days) including mortality, MACCE and functional status were available for 677 consecutive patients enrolled in the prospective MiTra Ulm registry from January 2010 to April 2019. The initial 340 patients treated in our institution before January 2016 were compared with the following 337 patients; (3) Results: Patients treated after 2016 showed significantly less ventricular dilatation (left ventricular end-systolic diameter of 43 ± 13 mm vs. 49 ± 16 mm, p p = 0.01) and a lower prevalence of severe tricuspid regurgitation (27.2% vs. 47.3%, p p p p = 0.047) and severe pulmonary hypertension (HR 2.18, p = 0.047) were predictors of long-term mortality only in patients treated before 2016. (4) Conclusions: The M-TEER candidates are currently treated earlier in the course of disease and benefit significantly in terms of a better long-term survival than patients treated at the beginning of the M-TEER era