Coronary artery bypass grafting (CABG) via full sternotomy remains a very invasive procedure, often requiring prolonged recovery of the patient. We describe a novel, less invasive approach for ...totally arterial CABG via a small left anterior thoracotomy in a pilot series of 20 unselected patients. From January to March 2020, 20 consecutive patients (mean age 65.9 ± 9.2 years, 100% male, STS-score: 1.6 ± 2) underwent CABG using only arterial conduits via a small left anterior thoracotomy. Patients were operated on cardiopulmonary bypass with peripheral cannulation and transthoracic aortic cross-clamping. Pulling tapes encircling the great vessels, the arrested empty heart was rotated and moved within the pericardium to enable conventional anastomotic techniques especially on lateral and inferior wall coronary targets. In all patients, left internal mammary artery and radial artery were utilized for bypass with 3.3 ± 0.7 distal coronary anastomoses per patient. Anterior, lateral, and inferior wall territories were revascularized in 100%, 85%, and 70% of patients, respectively. Complete anatomical revascularization was achieved in 95% of patients. ICU stay was 1 day in 17 patients, and 14 of patients left the hospital within 8 days. There was no hospital death, no stroke, no myocardial infarction, and no repeat revascularization. In this pilot series of 20 patients, minimally invasive, totally arterial CABG with avoidance of sternotomy was technically feasible with favorable patient outcomes.
Hereditary Transthyretin-Related Amyloidosis, a clinically heterogeneous autosomal dominant disease caused by pathogenic variants in the TTR gene, is characterized by the deposition of insoluble ...misfolded protein fibrils. The diagnosis, especially in non-endemic areas, is typically delayed by 4-5 years; a misdiagnosis due to clinical heterogeneity is common. The study objective was to define the prevalence of Hereditary Transthyretin-Related Amyloidosis in patients with polyneuropathy and/or cardiomyopathy of no obvious aetiology.
A multicenter observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis"-TRAM study was performed in Germany, Austria, and Switzerland.
A total of 5141 participants were recruited by 50 neurologic and 27 cardiologic specialized centres. Genetic analysis demonstrated a 1.1% Hereditary Transthyretin-Related Amyloidosis positivity rate among patients with polyneuropathy and/or cardiomyopathy of not obvious aetiology. Twenty-one various TTR variants (TTR-positive) were identified. Body Mass Index was lower in the TTR-positive patients as an indicator for the involvement of the autonomic nervous system; the age of onset of clinical manifestations was higher in TTR-positive patients. There were no other genotype-phenotype correlations or the prevalence of specific clinical manifestations in TTR-positive patients.
Our data support the fact that Hereditary Transthyretin-Related Amyloidosis is underdiagnosed in polyneuropathy and cardiomyopathy patients. Routine implementation of genetic testing is recommended in patients with unexplained polyneuropathy and/or cardiomyopathy to accelerate the earlier diagnosis and the time-sensitive treatment initiation.
KEY MESSAGES
More than 5.000 participants with CM and/or PNP of no obvious aetiology were recruited in the observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis" TRAM study and screened for pathogenic TTR variants.
The study demonstrated >1% of patients with CM and/or PNP of unclear aetiology are positive for a pathogenic TTR variant.
Routine genetic testing is recommended in patients with unexplained CM and/or PNP to accelerate the initial diagnosis and timely treatment initiation.
Studies assessing transfemoral transcatheter aortic valve implantation (TF-TAVI) showed lower rates of in-hospital mortality at high-volume hospitals and minimum caseloads were recommended to assure ...quality standards.
All patients in the German mandatory quality assurance registry with elective or urgent TF-TAVI procedures in 2018 and 2019 at 81 and 82 hospitals, respectively, were analysed. Observed in-hospital mortality was adjusted to expected mortality by the German AKL-KATH score (O/E) as well as by the EuroScore II (O/E2). Hospital volume and O/E were correlated by regression analyses and volume quartiles. 18 763 patients (age: 81.1 ± 1.0 years, mean EuroSCORE II: 6.9 ± 1.8%) and 22 137 patients (mean age: 80.7 ± 3.5 years, mean EuroSCORE II: 6.5 ± 1.6%) were analysed in 2018 and 2019, respectively. The average observed in-hospital mortality was 2.57 ± 1.83% and 2.36 ± 1.60%, respectively. Unadjusted in-hospital mortality was significantly inversely related to hospital volume by linear regression in both years. After risk adjustment, the association between hospital volume and O/E was statistically significant in 2019 (R2 = 0.049; P = 0.046), but not in 2018 (R2 = 0.027; P = 0.14). The variance of O/E explained by the number of cases in 2019 was low (4.9%). Differences in O/E outcome between the first and the fourth quartile were not statistically significant in both years (1.10 ± 1.02 vs. 0.82 ± 0.46; P = 0.26 in 2018; 1.16 0 .97 vs. 0.74 ± 0.39; P = 0.084 in 2019). Any chosen volume cut-off could not precisely differentiate between hospitals with not acceptable quality (>95th percentile O/E of all hospitals) and those with acceptable (O/E ≤95th percentile) or above-average (O/E < 1) quality. For example, in 2019 a cut-off value of 150 would only exclude one of two hospitals with not acceptable quality, while 20 hospitals with acceptable or above-average quality (25% of all hospitals) would be excluded.
The association between hospital volume and in-hospital mortality in patients undergoing elective TF-TAVI in Germany in 2018 and 2019 was weak and not consistent throughout various analytical approaches, indicating no clinical relevance of hospital volume for the outcome. However, these data were derived from a healthcare system with restricted access to hospitals to perform TAVI and overall high TAVI volumes. Instead of the unprecise surrogate hospital volume, the quality of hospitals performing TF-TAVI should be directly assessed by real achieved risk-adjusted mortality.
Abstract Background Optimal management of patients with persistent foramen ovale (PFO) following cryptogenic stroke or transient ischemic attack (TIA) suspected for paradoxical embolic events is ...still unclear. PFO closure has the potential benefit of preventing recurrent embolic events and avoiding serious bleeding resulting from long-term anticoagulation. Despite the widespread usage of closure devices, no randomized trial supports the general percutaneous closure approach. In addition, only mid-term, but not long-term, outcomes have been reported until now. The aim of the study is to assess clinical characteristics and long-term clinical outcome of patients undergoing percutaneous PFO closure. Methods Included in this single-center registry trial were 146 consecutive patients who underwent percutaneous closure of PFO at the University Hospital Frankfurt from 2000 to 2009. Periprocedural outcomes and long-term events were assessed. Follow-up was available in 146 patients (100%) with a mean follow-up of 7.8 ± 3.1 years (cumulative 1148 patient-years). Results The cerebroischemic event leading to indicate percutaneous PFO closure was TIA (34.9%), stroke without sequels (38.4%), stroke with sequels (24.7%), amaurosis fugax ( N = 2; 1.4%), and peripheral emboli ( N = 1; 0.7%). Only one severe periprocedural complication occurred (device dislocation). The majority of patients ( N = 143; 97.9%) experienced no further events during follow-up. Conclusion This “all-comers” population documents the safety of percutaneous PFO closure. The cardiovascular event rate is slightly lower (0.26 per 100 patient years) compared to the recently published randomized trials and maintained persistently low rate for more than 8 years.
Background
Transcatheter aortic valve implantation (TAVI) for aortic stenosis in older patients is the standard of care with a well-established supply density in Germany. In the near future, ...healthcare reform is planned that may affect TAVI capacities. Therefore, it is important to know how political regulations may interfere with access to services and what the need for TAVI will be in the future, based on demographic trends.
Methods
The number of TAVI procedures (DRG F98A +F98) and the in-hospital main diagnoses of aortic stenosis (ICD I35) in 2021 were analyzed at the level of county or federal state based on anonymized data from hospital reports, according to § 21 of the German hospital reimbursement law. The number of TAVI and aortic stenosis cases was projected for 2035 based on data from the German Federal Statistical Office on demographic developments. With quality assurance data from hospitals in 2019 and a route planner, the travel time to the next hospital performing TAVI (OPS 5‑35a.0) was calculated, and the consequence of a politically suggested minimum volume cut-off was analyzed.
Results
In 2021, a total of 26,506 TAVI procedures were reported with a mean number of TAVI per 100,000 inhabitants of 32 (range between federal states from 25 to 42). Among the 66,045 diagnoses of aortic stenosis, there was a variation per 100,000 inhabitants from 64 to 108 (mean 79) between federal states. Compared to 2021, an additional 8748 (+13%) diagnoses of aortic stenosis and an increase of 4673 (+18%) TAVI procedures is to be expected in 2035. In 2019, 57% of German citizens could reach a TAVI hospital within 30 min and 91% within 60 min of driving time by car (mean time to hospital 31 min). Applying a minimum number of 150 TAVI/hospital per year would increase the driving time to hospital from 33 to 52 min in Saxony-Anhalt and instantly remove six out of eight hospitals from service in Hesse.
Conclusion
Regulation of TAVI services by minimum volume numbers would arbitrarily interfere with access to services, in contradiction to the medical service assurance tasks of federal state governments. These issues should be considered in the upcoming healthcare system reform.
Objective and background
We present a first description of a Heart Team (HT)-guided approach to coronary revascularization and its long-term effect on clinical events after percutaneous coronary ...intervention (PCI). The HT approach is a structured process to decide for coronary bypass grafting (CABG), PCI or conservative therapy in ad hoc situations as well as in HT conferences. As a hypothesis, during the long-term course after a PCI performed according to HT rules, a low number of late revascularizations, especially CABGs, are expected (F-PCI study).
Methods
In this monocentric study, the HT approach to an all-comer population was first analyzed and described in general with the help of a database. Next the use of a HT approach was described for a more homogeneous subgroup with newly detected CAD (1.CAD). Those patients in whom the HT decision was PCI (which was a 1.PCI) were then studied with the help of questionnaires for clinical events during a very long-term follow-up. Events were CABG, PCI, diagnostic catheterization (DCath) and death.
Results
A significant number of patients were presented to HT conferences: 22 % out of all 11,174 catheterizations, 24 % out of all 7867 CAD cases and 35 % out of 3408 1.CAD cases. Most of these patients had multi-vessel disease (MVD). Conference decisions were isolated CABG in 46–66 %, PCI in 10–14 %, valvular surgery in 9–16 %, HTx in 10–21 % (Endstage heart failure candidates for surgery) and conservative therapy (Medical or no therapy, additional diagnostic procedures or no adherence to recommended therapy) in 2–3 %. However, most PCIs, ad hoc and elective, were performed under Heart Team rules, but without conference. During follow-up of 1.PCI patients (Kaplan–Meier analysis), CABG occurred in only 15 % of patients, PCI in 37 % and DCath in 65 %; mortality of any course was 51 %. Mortalities were similar in one-vessel disease and in a population of the same year, matched for age and sex (
p
< 0.057), but mortality was higher in 1.PCI patients with MVD (
p
< 0.001). Beyond 2 years, Kaplan–Meier curves were linear.
Conclusion
The structured Heart Team approach is an effective tool for ad hoc and conference-based clinical decision-making with a sustained clinical benefit. This is demonstrated in low late CABG (and PCI) rates after a 1.PCI, without elevated mortality. The all-comer population supports the universal value of these data. Stable annual event rates late after PCI suggest a conversion to stable CAD. Heart Team conferences are also important tools in cases of valvular and end-stage heart disease.
Intracoronary infusion of progenitor cells derived from bone marrow in patients with healed myocardial infarction resulted in moderate but significant improvement in global and regional ventricular ...function. Circulating progenitor cells were less effective. The mechanisms underlying the benefit are uncertain. This line of research is in its early stages but may hold promise for the future.
Intracoronary infusion of progenitor cells derived from bone marrow in patients with healed myocardial infarction resulted in moderate but significant improvement in global and regional ventricular function.
Chronic heart failure is common, and its prevalence continues to increase.
1
Ischemic heart disease is the principal cause of heart failure.
2
Although myocardial salvage due to early reperfusion therapy has significantly reduced early mortality rates,
3
postinfarction heart failure resulting from ventricular remodeling remains a problem.
4
One possible approach to reversing postinfarction heart failure is enhancement of the regeneration of cardiac myocytes as well as stimulation of neovascularization within the infarcted area. Initial clinical pilot studies have suggested that intracoronary infusion of progenitor cells is feasible and may beneficially affect postinfarction remodeling processes in patients with acute myocardial infarction.
5
–
9
However, . . .
The infusion of bone marrow–derived progenitor cells into the infarct-related coronary artery after an acute myocardial infarction was associated with an absolute increase in the ejection fraction of ...5.5%. Determining whether this modest improvement in ventricular function will translate into a long-term clinical benefit will require larger trials with longer follow-up.
The infusion of bone marrow–derived progenitor cells into the infarct-related coronary artery after an acute myocardial infarction was associated with an absolute increase in the ejection fraction of 5.5%.
Prompt reperfusion of the infarct-related coronary artery has considerably improved the clinical outcome in patients with acute myocardial infarction.
1
Although contemporary reperfusion strategies using stent implantation and aggressive inhibition of platelet aggregation have been shown to increase myocardial salvage,
2
improvements in global left ventricular function are rather modest, despite the use of optimal reperfusion therapy.
3
,
4
Heart failure that develops after infarction remains a major cause of morbidity and mortality.
5
,
6
Experimental studies suggested that intravascular or intramyocardial administration of progenitor cells derived from bone marrow (BMC) or blood may contribute to functional regeneration of infarcted myocardium and enhance neovascularization . . .
Abstract Background Drug-eluting-stents (DES) reduce clinical restenosis, but have mostly failed to demonstrate a reduction in death or myocardial infarction. The aim of this study was to evaluate ...the prognostic impact of the introduction of DES in patients undergoing multivessel percutaneous coronary intervention (MV-PCI). Methods Survival was assessed in 679 consecutive patients, who underwent PCI in at least two main vessels. Follow-up was available in 667 patients (98%) with a mean follow-up of 4.8 ± 2.5 years. We compared several scenarios: firstly, patients receiving at least one DES (≥1 DES group) vs. bare metal stent (BMS)-only patients (BMS only); secondly, the population was divided into a pre-DES-era (2000–2003; N = 257) and a DES-era (2004–2006; N = 422). Results 316 patients (47%) were treated for acute myocardial infarction (MI; N = 176 ST-elevation MI; N = 140 non-ST-elevation MI). On average, 2.2 ± 0.4 vessels were treated and 212 patients received at least one DES. The DES group showed a higher number of diseased (2.5 ± 0.6 vs. 2.4 ± 0.5; p = 0.02) and treated vessels (2.2 ± 0.5 vs. 2.1 ± 0.3; p < 0.01) and received more stents (3.3 ± 1.4 vs. 3.0 ± 1.1; p < 0.01). The BMS group presented more frequently with acute MI (55% vs. 29%; p < 0.01). The DES group showed more complex disease as evidenced by a higher SYNTAX-Score (17.4 ± 8.5 vs. 14.5 ± 8.3; p < 0.01). Restricting the survival analysis to patients with stable coronary artery disease, a significant prognostic advantage was found for patients received at least one DES compared to the BMS group (hazard ratio 0.58, 95% confidence interval 0.34–0.99) in the multivariate cox-regression-analysis. Conclusion The introduction of DES leads to extension of treatment to more complex patients. The use of DES is associated with improved survival in stable patients undergoing MV-PCI.
Transcatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option in high-risk patients with severe aortic stenosis.
PARTNER EU is the first study to evaluate prospectively the ...procedural and mid-term outcomes of transfemoral (TF) or transapical (TA) implantation of the Edwards SAPIEN® valve involving a multi-disciplinary approach.
Primary safety endpoints were 30 days and 6 months mortality. Primary efficacy endpoints were haemodynamic and functional improvement at 12 months. One hundred and thirty patients (61 TF, 69 TA), aged 82.1 ± 5.5 years were included. TA patients had higher logistic EuroSCORE (33.8 vs. 25.7%, P = 0.0005) and more peripheral disease (49.3 vs. 16.4%, P< 0.0001). Procedures were aborted in four TA (5.8%) and six TF cases (9.8%). Valve implantation was successful in the remaining patients in 95.4 and 96.4%, respectively. Thirty days and 6 months survival were 81.2 and 58.0% (TA) and 91.8 and 90.2% (TF). In both groups, mean aortic gradient decreased from 46.9 ± 18.1 to 10.9 ± 5.4 mmHg 6 months post-TAVI. In total, 78.1 and 84.8% of patients experienced significant improvement in New York Heart Association (NYHA) class, whereas 73.9 and 72.7% had improved Kansas City Cardiomyopathy Questionnaire (KCCQ) scores in TA and TF cohorts, respectively.
This first team-based multi-centre European TAVI registry shows promising results in high-risk patients treated by TF or TA delivery. Survival rates differ significantly between TF and TA groups and probably reflect the higher risk profile of the TA cohort. Optimal patient screening, approach selection, and device refinement may improve outcomes.
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