Chest Pain Unit Network in Germany Münzel, Thomas, MD; Heusch, Gerd, MD
Journal of the American College of Cardiology,
05/2017, Letnik:
69, Številka:
19
Journal Article
...a radical view on the contractile machinery in failing human myocardium is worthwhile and promises an avenue for therapeutic intervention, provided there is radical progress in our mechanistic ...understanding.
Objectives This study sought to evaluate whether supra-aortic angiography during preparatory balloon aortic valvuloplasty (BAV) improves valve sizing. Background Current recommendations for valve ...size selection are based on annular measurements by transesophageal echocardiography and computed tomography, but paravalvular aortic regurgitation (PAR) is a frequent problem. Methods Data of 270 consecutive patients with either conventional sizing (group 1, n = 167) or balloon aortic valvuloplasty–based sizing (group 2, n = 103) were compared. PAR was graded angiographically and quantitatively using several hemodynamic indices. Results PAR was observed in 113 patients of group 1 and 41 patients of group 2 (67.7% vs. 39.8%, p < 0.001). More than mild PAR was found in 24 (14.4%) patients of group 1 and 8 (7.8%) patients of group 2. According to pre-interventional imaging, 40 (39%) patients had a borderline annulus size, raising uncertainty regarding valve size selection. Balloon sizing resulted in selection of the bigger prosthesis in 30 (29%) and the smaller prosthesis in the remaining patients, and only 1 of these 40 patients had more than mild PAR. As predicted by the hemodynamic indices of PAR, mortality at 30 days and 1 year was less in group 2 than in group 1 (5.8% vs. 9%, p = 0.2 and 10.6% vs. 20%, p = 0.01). Conclusions Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation improves valve size selection, reduces the associated PAR, and increases survival in borderline cases.
The functional importance of alpha2-adrenergic coronary vasoconstriction was first demonstrated in dogs (4,5) and subsequently confirmed in humans in relevant clinical settings such as percutaneous ...coronary intervention (6-9). ...in the context of alpha-adrenergic coronary vasoconstriction, the "in vivo over in vitro" may outweigh the "human over animal" preference; studies in dogs are particularly suited because their coronary vascular alpha-adrenoceptor distribution is largely identical to that of humans (5,6).
Abstract Background We investigated the current management of unstable angina pectoris (UAP) in certified chest pain units (CPUs) in Germany and focused on the European Society of Cardiology (ESC) ...guideline-adherence in the timing of invasive strategies or choice of conservative treatment options. More specifically, we analyzed differences in clinical outcome with respect to guideline-adherence. Method Prospective data from 1400 UAP patients were collected. Analyses of high-risk criteria with indication for invasive management and 3-month clinical outcome data were performed. Guideline-adherence was tested for a primarily conservative strategy as well as for percutaneous coronary intervention (PCI) within <24 and <72 h after admission. Results Overall guideline-conforming management was performed in 38.2%. In UAP patients at risk, undertreatment caused by an insufficient consideration of risk criteria was obvious in 78%. Reciprocally, overtreatment in the absence of adequate risk markers was performed in 27%, whereas a guideline-conforming primarily conservative strategy was chosen in 73% of the low-risk patients. Together, the 3-month major adverse coronary and cerebrovascular events (MACCE) were low (3.6%). Nonetheless, guideline-conforming treatment was even associated with significantly lower MACCE rates (1.6% vs. 4.0%, p < 0.05). Conclusion The data suggest an inadequate adherence to ESC guidelines in nearly two thirds of the patients, particularly in those patients at high to intermediate risk with secondary risk factors, emphasizing the need for further attention to consistent risk profiling in the CPU and its certification process.
Abstract Background Sphingosine-1-phosphate (S1P) is a constituent of high-density lipoproteins (HDL) that contributes to their beneficial effects. We have shown decreased HDL-S1P in coronary artery ...disease (CAD) but its functional relevance remains unclear. Objectives This study investigated the functional consequences of reduced HDL-S1P content in CAD and tested if increasing it may improve or restore HDL function. Methods Human HDL from healthy and CAD subjects, as well as mouse HDL, were isolated by ultracentrifugation. HDL-S1P-dependent activation of cell-signaling pathways and induction of vasodilation were examined in vitro and in isolated arteries using native and S1P-loaded HDL, S1P receptor antagonists, and S1P-blocking antibodies. Results HDL-S1P-dependent signaling was clearly impaired and S1P content reduced in CAD-HDL as compared to healthy HDL. Both healthy and CAD-HDL could be efficiently and equally well loaded with S1P from cellular donors and plasma. S1P-loading greatly improved HDL signaling and vasodilatory potential in pre-contracted arteries and completely corrected the defects inherent to CAD-HDL. HDL-S1P content and uptake was reduced by oxidation and was lower in HDL3 than HDL2 . Loading with S1P in vitro and in vivo fully replenished the virtually absent S1P content of apolipoprotein M-deficient HDL and restored their defective signaling. Infusion of erythrocyte-associated C17-S1P in mice led to its rapid and complete uptake by HDL providing a means to directly S1P-load HDL in vivo. Conclusions Reduced HDL-S1P content contributes to HDL dysfunction in CAD. It can be efficiently increased by S1P-loading in vitro and in vivo, providing a novel approach to correcting HDL dysfunction in CAD.
Abstract Objectives This study sought to analyze health-related quality-of-life (HrQoL) outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) based on data from GARY (German ...Aortic Valve Registry). Background Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities, and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality in this high-risk patient population. Methods In 2011, 3,875 patients undergoing TAVR were included in the GARY registry. HrQoL was prospectively measured using the EuroQol 5 dimensions questionnaire self-complete version on paper at baseline and 1 year. Results Complete follow-up EuroQol 5 dimensions questionnaire evaluation was available for 2,288 patients (transvascular transcatheter aortic valve replacement TAVR-TV: n = 1,626 and transapical TAVR TAVR-TA: n = 662). In-hospital mortality was 5.9% (n = 229) and the 1-year mortality was 23% (n = 893). The baseline visual analog scale score for general health status was 52.6% for TAVR-TV and 55.8% for TAVR-TA and, in parallel to an improvement in New York Heart Association functional class, improved to 59.6% and 58.5% at 1 year, respectively (p < 0.001). Between baseline and 1 year, the number of patients reporting no complaints increased by 7.8% (TAVR-TV) and by 3.5% within the mobility dimension, and by 14.1% (TAVR-TV) and 9.2% within the usual activity dimension, whereas only moderate changes were found for the self-care, pain or discomfort, and anxiety or depression dimensions. In a multiple linear regression analysis several pre- and post-operative factors were predictive for less pronounced HrQoL benefits. Conclusions TAVR treatment led to improvements in HrQoL, especially in terms of mobility and usual activities. The magnitude of improvements was higher in the TAVR-TV group as compared to the TAVR-TA group. However, there was a sizable group of patients who did not derive any HrQoL benefits. Several independent pre- and post-operative factors were identified being predictive for less pronounced HrQoL benefits.
Reply to the Editor Kottenberg, Eva, MD; Peters, Jürgen, MD; Heusch, Gerd, MD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
09/2013, Letnik:
146, Številka:
3
Journal Article
Systematic Analysis of Functional and Structural Changes After Coronary Microembolization: A Cardiac Magnetic Resonance Imaging Study Frank Breuckmann, Kai Nassenstein, Christina Bucher, Ina ...Konietzka, Gernot Kaiser, Thomas Konorza, Christoph Naber, Andreas Skyschally, Petra Gres, Gerd Heusch, Raimund Erbel, Jörg Barkhausen This study aimed to detect the early effects of coronary microembolization (ME) by cardiac magnetic resonance (CMR). Eighteen minipigs were studided from 30 min to 8 h after ME. Cine CMR imaging demonstrated a time-dependent increase of wall motion abnormalities in all animals by 8 h. Only 4 of the animals showed myocardial edema on T2-weighted imaging, whereas there was a progressive increase in the number of animals showing late gadolinium enhancement (LGE) by 8 h. Ex vivo CMR imaging showed patchy areas of LGE. Coronary microemboli cause patchy necrosis and progressive left ventricular dysfunction in the first 8 h after the event as detected by CMR.
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