Transkatheter-Aortenklappenimplantation (TAVI) bei multivalvulären Herzerkrankungen

Transcatheter Aortic Valve Implantation in Multivalvular Heart Disease Abstract. The prevalence of multivaluvular heart disease is high in patients undergoing transcatheter aortic valve implantation (TAVI). The most common combination is aortic valve stenosis (AS) and mitral regurgitation, followed by the combination of AS with a tricuspid regurgitation or mitral stenosis. Grading of multivalvular disease is challenging and can quickly lead to underestimation of the disease stage. Therefore, a profound knowledge of pathophysiologic interactions is essential, and the patient should always undergo multimodal evaluation. After a successful TAVI intervention, secondary heart valve defects may improve, deteriorate, or remain unchanged. Due to the still sparse scientific data in this field, the role of the heart team remains central to provide the patient with an individually adapted therapy plan.Die Prävalenz von multivalvulären Herzerkrankungen ist bei TAVI (Transcatheter Aortic Valve Implantation)-Patientinnen und -Patienten hoch. Am häufigsten findet sich die Kombination Aortenklappenstenose (AS) und Mitralinsuffizienz, gefolgt von der Kombination AS und Trikuspidalinsuffizienz oder AS und Mitralstenose. Die Graduierung von multivalvulären Erkrankungen ist anspruchsvoll und führt oft zu einer Unterschätzung des Krankheitsstadiums. Daher ist ein profundes Wissen über die pathophysiologischen Zusammenhänge zentral, und die Patientinnen und Patienten sollten stets multimodal abgeklärt werden. Nach einer erfolgreichen TAVI können sich sekundäre zusätzliche Klappenprobleme verbessern, aber auch unbeeinflusst bleiben oder sich sogar verschlechtern. Die wissenschaftliche Datenlage bei multivalvulären Erkrankungen ist spärlich. Nicht zuletzt deshalb bleibt die Rolle des «Heart Teams» zentral, um Patientinnen und Patienten einen individuell angepassten Therapievorschlag unterbreiten zu können

Dreidimensionale Echokardiographie zur Beurteilung der Mitralklappe

Using two-dimensional echocardiography, the complex anatomy of the mitral valve needs mental reconstruction into its three-dimensional shape. The power of both transthoracic and transesophageal three-dimensional echocardiography (3DE) lies in its possibility of showing the complex mitral valve anatomy in one single image, as opposed to the mental reconstruction based on multiple two-dimensional images and schematic assumptions. Several 3DE modalities are used in daily life, including real time (“live”) modes as wells as postprocessed images. 3DE is of special interest in the evaluation of mitral stenosis, complex mitral valve prolapse and mitral valve prostheses. It has an established role in the perioperative mitral valve assessment during mitral valve surgery as well as during percutaneous mitral valve procedures. Limitations of 3DE are relatively low frame rates, an important learning curve as well as timeconsuming processing

Gender, age, and body surface area are the major determinants of ascending aorta dimensions in subjects with apparently normal echocardiograms.

BACKGROUND: Limited data have been published on the normal size of the ascending aorta (AA) measured using transthoracic echocardiography (TTE). METHODS: AA diameters were measured in 1799 patients with normal cardiac findings on TTE and compared with the diameters of the sinus of Valsalva (SoV). RESULTS: Mean diameters in men and women, respectively, were 3.4 and 3.1 cm for the SoV and 3.2 and 3.0 cm for the AA. The sizes of the SoV and the AA showed strong correlations with age, age squared, and body surface area. The 5th and 95th percentile curves for the SoV and AA showed faster growth of diameters in early adulthood compared with old age. The dimensions of the SoV were larger than those of the AA (mean differences, 0.19 cm in men and 0.08 cm in women), and the difference between the SoV and AA was negatively correlated with age. CONCLUSION: The findings of this study stress the importance of indexing dimensions of the SoV and the AA to age and body surface area separately for men and women

High prevalence of baffle leaks in adults after atrial switch operations for transposition of the great arteries

Aims To determine the prevalence of baffle leaks in adults after atrial switch operations for transposition of the great arteries, as these may predispose to paradoxical embolic events, particularly in patients with transvenous pacemaker or defibrillator leads. Methods and Results We routinely perform contrast echocardiography with agitated saline in all patients after atrial switch operations. For this study, we analysed patients who had saline contrast echocardiography between 2010 and 2012. The presence of baffle leaks and the severity of right-to-left shunting were assessed. We compared baseline characteristics and oxygen saturation at rest and during exercise between patients with and without baffle leaks. A total of 65 patients (56 Senning and 9 Mustard repair) without previously known baffle leaks were included (mean age 32 ± 8 years, 77% males). Right-to-left shunting was identified in 42 patients (65%) and occurred without provocation manoeuvres in 88%. There were no differences in baseline characteristics, echocardiographic findings, or exercise capacity between patients with and without baffle leaks, except for lower oxygen saturation at peak exercise in those with baffle leaks (29% had oxygen saturations below 90% at peak exercise compared to none without baffle leaks, P = 0.011). Four patients with baffle leaks had previous implantation of transvenous pacemaker leads; one of them had suffered a stroke. Two other patients with baffle leaks had a history of potential embolic stroke. Conclusions Because of the high prevalence of baffle leaks in adults after atrial switch operations, we propose routine screening with agitated saline contrast, particularly prior to implantation of transvenous pacemaker or defibrillator leads

Heart rate profiles and heart rate variability during scuba diving

AIMS: The aim of the present study was to describe heart rate profiles and heart rate variability patterns in non-selected scuba divers of different ages under non-experimental real-world conditions. METHODS: We used specially designed silver-loaded polydimethylsiloxane dry electrodes for underwater ECG recordings. With a custom-built setup, heart rate profiles and heart rate variability patterns were documented before submersion, during diving and after resurfacing in 18 separate dives. RESULTS: Heart rates of the divers just before descent were remarkably high (median 114 bpm, interquartile range [IQR] 83–154) with a statistically significant rapid decrease after submersion (median 90 bpm, IQR 70–116; p = 0.008). The percentage heart rate reduction by submersion was individually very variable (median 21%, range 5–39%). We noted a general increase in autonomic nervous system (ANS) activity without predominance of parasympathetic parameters, suggesting a concomitant sympatheticadrenergic activation. CONCLUSIONS: Scuba diving under real-world conditions by non-selected divers is characterised by relatively high heart rates just before submersion, an individually variable but significant bradycardic dive response, and induces an immediate and sustained parallel increase of parasympathetic and sympathetic-adrenergic autonomic nervous system activity. These observations could explain several specific pathophysiological mechanisms of diving incidents (haemodynamic decompensation, arrhythmias, acute coronary syndromes) and underlines the importance of cardiovascular risk stratification in diving eligibility assessment