Left atrial appendage closure for “primary primary” prevention during percutaneous closure of septal defects in patients with large atria but no atrial fibrillation

  Background: Percutaneous atrial septal defect (ASD) closure is a routine procedure to prevent right ventricular failure, pulmonary hypertension, or paradoxical embolism. The latter is the typical reason for percutaneous patent foramen ovale (PFO) closure. Atrial enlargement represents a risk for develop­ing atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) closure is emerging as a preven­tive therapy for patients in AF who suffered from a previous stroke or bleeding (secondary prevention) or patients without previous stroke or bleeding (primary prevention). Percutaneous septal closure, particularly that of large ASDs, may inhibit future percutaneous left atrial access when required for LAA closure. Reported herein is the feasibility and safety of concomitant percutaneous closure of the LAA and a septal shunt, mostly large ASDs, in patients without AF, in the sense of “primary primary” preventive LAA closure. The first “primary” relates to “in anticipation of AF” and potentially also for “for prevention of AF”. The second “primary” relates to “prevention of stroke or bleeding”. Methods: Thirteen consecutive patients, older than 40 years without any clinical or electrocardio­graphic evidence of AF, underwent percutaneous closure of large ASDs or PFOs in the presence of enlarged atria at the university hospitals of Bern and Zurich between April 2013 and June 2015. They concomitantly received “primary primary” preventive LAA closure after informed consent. Results Mean patient age was 58 ± 9 years (46% male). Procedural success was achieved in all pa­tients and no major adverse events occurred acutely or during the following 2.0 ± 0.8 years. No patient developed AF. Conclusions: Concomitant closure of ASD or PFO in the presence of enlarged atria and LAA for “primary primary” prevention appears feasible and safe but has yet to prove its justification

Long-term prognostic value of dobutamine stress CMR

Das Ziel dieser Studie war es, die prognostische Wertigkeit der DSMR für die Vorhersage kardialer Ereignisse bei Patienten mit bekannter KHK oder Verdacht auf KHK nach einer ausreichend langen Nachbeobachtung und in einer großen Patientenpopulation zu ermitteln. Es wurden die klinischen Daten, hämodynamischen Daten und DSMR-Resultate von 1463 Patienten, bei welchen eine DSMR-Untersuchung zwischen 01/2000 and 12/2004 am Deutschen Herzzentrum Berlin durchgeführt wurde, retrospektiv betrachtet. Bei 1369 dieser Patienten konnte eine Nachbeobachtung durchgeführt werden. „Kardiale Ereignisse“ wurden als kardialer Tod und Myokardinfarkt definiert. „Gesamte Ereignisse“ wurden definiert als „Kardiale Ereignisse“ plus Tod nicht kardialer Ursache, Revaskularisation sowie Hospitalisation und zusätzlich dokumentiert. Bei 352 Patienten wurde eine Revaskularisation innerhalb von 3 Monaten nach DSMR durchgeführt. Diese Patienten wurden von der Hauptanalyse ausgeschlossen, um sicher zu gehen, dass die Revaskularisation nicht das kardiale Ereignis bedingt und in einer Subgruppenanalyse untersucht. Die beobachtete Population wurde in zwei Gruppen geteilt, basierend darauf, ob der primäre Endpunkt („kardiales Ereignis“) erreicht wurde oder nicht. Unterschiede in den Patientendaten, DSMR-Daten und hämodynamischen Daten der beiden Gruppen wurden verglichen und univariate sowie multivariate Analysen durchgeführt. In einer Kaplan-Meier-Analyse wurden Unterschiede im Überleben frei von „kardialen Ereignissen“ und frei von „gesamten Ereignissen“ bei Patienten mit und ohne Wandbewegungsstörungen dargestellt. In einer Subgruppenanalyse wurden die Patienten mit früher Revaskularisation (352 Patienten) weiter betrachtet und mit den verbleibenden 1017 Patienten mit medikamentöser Therapie verglichen. Die 1017 Patienten der Hauptgruppe (mittleres Alter 62 Jahre) konnten für 44 ± 24 Monaten nachbeobachtet werden (Median 38 Monate). Während der Nachbeobachtungszeit zeigten 46 (4,5%) Patienten ein kardiales Ereignis. Die mittlere Zeit zwischen DSMR-Untersuchung und kardialem Ereignis betrug 36 ± 18 Monate. Es starben 33 (3,2%) unserer Patienten an einer kardialen Ursache (kardialer Tod), 13 (1,3%) Patienten zeigten einen Myokardinfarkt (primärer Endpunkt). Tod nicht kardialer Ursache trat bei 23 (2,3%) Patienten auf. Während der Nachbeobachtungszeit wurden 109 (10,7%) Patienten hospitalisiert, fünf Patienten (0,5%) wegen ventrikulärer Rhythmusstörungen, 104 Patienten (10,2%) aufgrund einer instabiler AP. Eine Revaskularisation drei Monate nach DSMR wurde bei 148 (14,5%) durchgeführt, eine PTCA bei 115 (11,3%) Patienten, ein Bypass wurde bei 33 (3,2%) Patienten angelegt (sekundärer Endpunkt). Unsere Ergebnisse belegen unabhängig von klinischen Einflussfaktoren, dass Patienten, welche induzierte Wandbewegungsstörungen in der DSMR zeigten, ein erhöhtes Risiko für das Auftreten von kardialen Ereignissen (kardialem Tod und Myokardinfarkt) haben. Für Patienten, welche eine normale Wandbewegung unter Hochdosis-DSMR zeigten, ergab sich eine sehr gute Prognose mit einem ereignisfreien 6-Jahres-Überleben ohne Myokardinfarkt und kardialen Tod von 96,8%. Es zeigte sich eine jährliche Ereignisrate von 1,1% über 6 Jahre (0,8% in den ersten drei Jahren und 1,4% vom 4. bis zum 6. Jahr) für eine normale DSMR-Untersuchung. Diese Ergebnisse in einer ausreichend großen Patientenanzahl sowie Ereignisrate bestätigen die Ergebnisse der ersten DSMR- Prognose-Studien in kleineren Kollektiven mit kürzerem Follow-up. Zusätzlich konnten wir nachweisen, dass Patienten mit induzierten Wandbewegungsstörungen und daraus resultierender folgender Revaskularisation (innerhalb von 3 Monaten) eine deutlich niedrigere Ereignisrate aufwiesen als Patienten mit alleiniger medikamentös-konservativer Therapie, dieses Ergebnis war jedoch aufgrund der Fallzahl statistisch nicht signifikant.OBJECTIVES: The aim of this study was to assess the long-term value of high- dose dobutamine cardiac magnetic resonance (DCMR) for the prediction of cardiac events in a large cohort of patients with known or suspected coronary artery disease. BACKGROUND: High-dose DCMR has been shown to be a useful technique for diagnosis and intermediate-term prognostic stratification. METHODS: Clinical data and DCMR results were analyzed in 1,463 consecutive patients undergoing DCMR between 2000 and 2004. Ninety-four patients were lost to follow-up. The remaining 1,369 patients were followed up for a mean of 44 ± 24 months. Cardiac events, defined as cardiac death and nonfatal myocardial infarction, were related to clinical and DCMR results. RESULTS: Three-hundred fifty-two patients underwent early revascularization (≤ 3 months of DCMR) and were excluded from analysis. Of the remaining 1,017 patients, 301 patients (29.6%) experienced inducible wall motion abnormalities (WMA). Forty-six cardiac events were reported. In those with and without inducible WMA, the proportion of patients with cardiac events was 8.0% versus 3.1%, respectively, p = 0.001 (hazard ratio: 3.3; 95% confidence interval: 1.8 to 5.9 for the presence of inducible WMA; p < 0.001). A DCMR without inducible WMA carried an excellent prognosis, with a 6-year cardiac event-free survival of 96.8%. In all 1,369 patients in the patient group with stress-inducible WMA, those patients with medical therapy demonstrated a trend to a higher cardiac event rate (8.0%) than those with early revascularization (5.4%) (p = 0.234). Patients with normal DCMR and medical therapy or early revascularization demonstrated similar cumulative cardiac event rates (3.1% vs. 3.2%, p = 0.964). CONCLUSIONS: In a large cohort of patients, DCMR has an added value for predicting cardiac events during long-term follow-up, improving the differentiation between high-risk and low-risk patients. Patients with inducible WMA and following early revascularization, demonstrate lower cardiac event rates than patients with medical therapy alone

Left atrial appendage closure for primary primary prevention during percutaneous closure of septal defects in patients with large Atria but no Atrial Fibrillation

BACKGROUND Percutaneous atrial septal defect (ASD) closure is a routine procedure to prevent right ventricular failure, pulmonary hypertension, or paradoxical embolism. The latter is the typical reason for percutaneous patent foramen ovale (PFO) closure. Atrial enlargement represents a risk for developing atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) closure is emerging as a preventive therapy for patients in AF who suffered from a previous stroke or bleeding (secondary prevention) or patients without previous stroke or bleeding (primary prevention). Percutaneous septal closure, particularly that of large ASDs, may inhibit future percutaneous left atrial access when required for LAA closure. Reported herein is the feasibility and safety of concomitant percutaneous closure of the LAA and a septal shunt, mostly large ASDs, in patients without AF, in the sense of primary primary preventive LAA closure. The first "primary" relates to "in anticipation of AF" and potentially also for "for prevention of AF". The second "primary" relates to "prevention of stroke or bleeding". METHODS Thirteen consecutive patients, older than 40 years without any clinical or electrocardiographic evidence of AF, underwent percutaneous closure of large ASDs or PFOs in the presence of enlarged atria at the university hospitals of Bern and Zurich between April 2013 and June 2015. They concomitantly received primary primary preventive LAA closure after informed consent. RESULTS Mean patient age was 58 ± 9 years (46% male). Procedural success was achieved in all patients and no major adverse events occurred acutely or during the following 2.0 ± 0.8 years. No patient developed AF. CONCLUSIONS Concomitant closure of ASD or PFO in the presence of enlarged atria and LAA for primary primary prevention appears feasible and safe but has yet to prove its justification

Management of complications in long-term LVAD support

INTRODUCTION: Management of complications in long-term LVAD support like aortic regurgitation, progressive decline of right ventricular function, or pump thrombosis are challenging.
 METHODS AND RESULTS: After 2.5 years on a HeartMate II left ventricular assist device (LVAD) a 59-year-old patient was admitted to hospital due to severe hemolysis caused by a partial occlusion and thrombosis caused by a shift of the LVAD inflow cannula towards the lateral wall of the left ventricle (LV). Preoperative assessment revealed additional severe aortic regurgitation and impaired right ventricular (RV) function (severe tricuspid regurgitation, RV ejection fraction 25%, central venous pressure 14 mmHg). After LVAD device exchange and aortic valve replacement (AVR) RV failure occurred and a temporary right ventricular assist device (RVAD) was employed. RVAD explantation was feasible 21 days after surgery. The patient was discharged to a rehabilitation center.
 DISCUSSION: In this case, LVAD exchange with concomitant AVR and temporary RVAD efforts saved the patient's life and restored a good quality of life

Expeditious and less traumatic explantation of a heartware LVAD after myocardial recovery

After 169 days on left ventricular assist device (LVAD) support, a 62-year-old male patient suffering from idiopathic dilatative cardiomyopathy showed signs of left ventricular recovery. Off-pump trials were done, and our explantation criteria were met. The LVAD removal procedure was performed after 338 days on the device, using a left lateral thoracotomy in the sixth intercostal space. First, the outflow graft was transected and the distal end was sewed. Then, the pump was replaced by an individually manufactured titanium plug. Finally, the driveline was cut so that the device could be completely withdrawn. The rest of the driveline was accessed through a small abdominal incision and explanted through the percutaneous exit site

Prehospital care of left ventricular assist device patients by emergency medical services

Left ventricular assist devices (LVADs) are frequently implanted as permanent (bridge to destination [BTD]) or temporary (bridge to transplantation [BTT]) cardiac support. When LVAD patients are discharged to home, they are very likely to require emergency medical services (EMS), but there is very little literature on out-of-hospital emergency care for patients with LVADs. We present two typical cases of LVAD patients for whom EMS was called. In the first case, the patient was in an ambulance two hours distant from our university hospital when a pulsatile system malfunctioned. In the second case, EMS was called to an unconscious LVAD patient. Emergency reference cards, training programs for emergency medical staff, and a 24-hour emergency hotline for the local VAD team are advisable

Herztransplantation - Goldstandard trotz Alternativen: Herzersatzverfahren

Weltweit leiden etwa 25 Millionen Menschen unter einer Herzinsuffizienz. Deren steigende Prävalenz ist auf die Fortschritte der Medizin und die höhere Lebenserwartung der Bevölkerung zurückzuführen. Während eine optimale medikamentöse Therapie der wichtigste Eckpfeiler in der Behandlung der Herzinsuffizienz ist, stellt die Herztransplantation auch heute noch die beste Option in der Behandlung der terminalen Herzinsuffizienz dar, wenn sämtliche konservative Möglichkeiten ausgeschöpft sind

Emergency procedures for patients with a continuous flow left ventricular assist device

The number of ventricular assist devices (VADs) being implanted for terminal heart failure is rising at an exponential rate. These implanted patients have a decreased mortality, but still have significant morbidities, as the prevalence of these patients increases in the community. When VAD patients are discharged to home, they will very likely require emergency medical services (EMSs) and emergency medical doctors (EDs) with their future care. The interface of these patients with the community would suggest an increasing prevalence of encounters requiring the need for acute medical care. This will place the initial responsibility of these patients in the hands of EMS first responders and emergency room providers. To date, there is very little literature published on out-of-hospital or ED care for VAD patients. Most EMS personnel and ED feel uncomfortable treating a patient with a VAD because they have not had sufficient exposure. The cardiovascular treatment of VAD patients in the field can pose different challenges typically encountered including difficulties measuring a pulse and sometimes undetectable BP. Despite these unique challenges, official guidelines or even standard operating procedures regarding the emergency treatment of VAD patients are still lacking. We present a basic overview of the most commonly used left VAD systems and propose guidelines that should be followed in the event of an emergency with a VAD patient out of hospital