Die chronische Nierenkrankheit (CKD) ist einer der wichtigsten Risikofaktoren für Herz-Kreislauf-Erkrankungen (CVD; manifestiert durch koronare Herzkrankheit, Herzinsuffizienz, Arrhythmien und plötzlichen Herztod), und das gleichzeitige Vorliegen sowohl von CVD und CKD hat einen erheblichen Einfluss auf die Prognose der Patienten. Die diagnostischen und therapeutischen Möglichkeiten kardiovaskulärer Erkrankungen sind bei fortgeschrittener CKD häufig eingeschränkt, und für viele interventionelle und medikamentöse Therapien besteht wenig oder keine Evidenz aus großen klinischen Studien. Das vorliegende Konsensuspapier gibt einen Überblick über die Besonderheiten kardiovaskulärer Erkrankungen bei CKD und fasst die aktuelle Evidenz und Empfehlungen zur Therapie von Patienten mit CVD und CKD zusammen.

Studies assessing transcatheter edge-to-edge mitral valve repair (M-TEER) suggest lower rates of in-hospital mortality (IHM) at high-volume hospitals, and guidelines recommend minimum caseloads to assure quality standards. Data from all patients undergoing M‑TEER procedures at 154 hospitals in the German mandatory quality assurance registry in 2020 were analyzed. The observed IHM was adjusted against the expected mortality predicted by the German MKL-KATH score (O/E) and EuroScore II (O/E2). Regression analyses and volume quartile analyses were performed on hospital volume (HV), IHM rate, O/E, and intra-hospital complications. Additionally, binomial analysis was performed to verify results. A total of 5099 patients (age 77.9 ± 2.5 years, mean EuroScore II 17.9 ± 5.9

Background:Transcatheter edge-to-edge repair (TEER) for the systemic atrioventricular valve has been anecdotally reported as a viable treatment option in symptomatic inoperable adult patients born with congenitally corrected transposition of the great arteries (ccTGA). However, to date, case reports on TEER treatment of both atrioventricular valves are lacking, especially when considering the present availability of specific mitral and tricuspid valve TEER devices. Case summary:We present the case of an 84-year-old man with recurrent admissions for acute heart failure due to high-grade regurgitation of both atrioventricular valves. The patient was first diagnosed with ccTGA at this advanced age and underwent a thorough multimodality imaging approach, including transthoracic and transoesophageal echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, and ventriculography of the systemic ventricle. Due to the high symptom burden despite optimal medical therapy and high doses of diuretics, the heart team recommended TEER, first for the systemic tricuspid valve and later on for the non-systemic mitral valve. Both complex procedures were uneventful and led to considerable improvement in quality of life. Discussion:Congenitally corrected transposition of the great arteries mostly manifests itself in adulthood and affects both ventricles and atrioventricular valves. In case of anatomical doubts on transthoracic echocardiography, a thorough multimodality imaging work-up is recommended. Transcatheter treatment of both atrioventricular valves seems to be a safe and effective therapeutic option in these often inoperable patients.

Perioperative mortality is the third most common cause of death after ischemic heart disease and stroke. Individual clinical risk assessment is therefore crucial. A relevant contribution to postoperative mortality is made by perioperative myocardial infarctions (PMI). In the majority of cases, these are clinically silent and are only recognized by systematic hs-TnT/I measurements. In the latest ESC guidelines for non-cardiac surgery, perioperative hs-TnT/I monitoring is, therefore, recommended. This is intended to detect and treat type 1 and type 2 myocardial infarctions more quickly. However, non-coronary causes such as cardiac arrhythmias, infections, sepsis, pulmonary embolism, renal dysfunction, stroke, subarachnoid hemorrhage and chronic lung diseases can also increase hs-TnT/I levels. Since many high-risk patients already have elevated hs-TnT/I values, preoperative assessment of hs-TnT/I levels should be performed.

Background:Tricuspid regurgitation (TR) is associated with increased morbidity and mortality. As many elderly TR patients are deemed inoperable, transcatheter edge-to-edge repair (T-TEER) is arising as a viable treatment option. Though procedural safety aspects seem excellent, long-term risks cannot be ignored, including the feasibility of cardiac pacing by endovascular lead implantation at a later time, as well as T-TEER device-related infective endocarditis (IE), in the context of systemic infection.Case summary:We present the case of an 80-year-old man with recurrent admissions for right heart failure due to massive TR, despite successful percutaneous mitral valve repair. The patient was turned down for surgery and eventually underwent T-TEER, with successful TR reduction to mild-to-moderate and improvement in quality of life. Five months later, the patient was admitted for symptomatic bradycardia and the first reported pacemaker implantation after T-TEER with a specific tricuspid valve device was performed. Lead implantation was guided by transoesophageal echocardiography, and did not worsen residual TR. Two years later, the patient presented with device-related tricuspid valve IE, again a 'first' following T-TEER. Despite antimicrobial therapy, the vegetation embolized through the atrial septal defect caused by prior mitral-TEER and triggered an ischaemic stroke. Furthermore, sepsis led to multiorgan failure and eventually death.Discussion:Tricuspid regurgitation is an individual predictor of morbidity and mortality, frequently found in elderly, and should be addressed in symptomatic inoperable patients. With the rise of interventional treatment, new challenges face long-term follow-up and treatment after percutaneous repair. This case report underscores the feasibility of endovascular pacemaker lead implantation after T-TEER, while it points to the risk of device-related tricuspid valve IE.

ZusammenfassungNach der koronaren Herzerkrankung und dem Schlaganfall stellt perioperative Mortalität die dritthäufigste Todesursache in den westlichen Industrieländern dar. Die individuelle, klinische Risikobewertung ist deswegen von besonderer Bedeutung. Die perioperative Mortalität beruht zum überwiegenden Anteil auf perioperativen Myokardinfarkten (PMI), die häufig klinisch stumm verlaufen und nur durch systematische hs-TnT/I-Messungen frühzeitig erkennbar werden. In den neuesten ESC-Leitlinien zu nicht kardialen, chirurgischen Eingriffen wird deswegen die perioperative hs-TnT/I-Überwachung empfohlen. Dadurch sollen Typ-1- und Typ-2-Myokardinfarkte schneller erkannt und behandelt werden. Auch nicht koronare Ursachen wie Herzrhythmusstörungen, Infektionen, Sepsis, Lungenembolie, Nierenfunktionsstörungen, Schlaganfall, Subarachnoidalblutung und chronische Lungenerkrankungen können zu einem hs-TnT/I-Anstieg führen. Da viele Hochrisikopatienten bereits präoperativ erhöhte hs-TnT/I-Werte aufweisen, sollte eine hs-TnT/I-Bestimmung bereits präoperativ durchgeführt werden.

AIMS:Patients with mitral regurgitation (MR) present with considerable heterogeneity in cardiac damage depending on underlying aetiology, disease progression, and comorbidities. This study aims to capture their cardiopulmonary complexity by employing a machine-learning (ML)-based phenotyping approach.METHODS AND RESULTS:Data were obtained from 1426 patients undergoing mitral valve transcatheter edge-to-edge repair (MV TEER) for MR. The ML model was developed using 609 patients (derivation cohort) and validated on 817 patients from two external institutions. Phenotyping was based on echocardiographic data, and ML-derived phenotypes were correlated with 5-year outcomes. Unsupervised agglomerative clustering revealed four phenotypes among the derivation cohort: Cluster 1 showed preserved left ventricular ejection fraction (LVEF; 56.5 ± 7.79%) and regular left ventricular end-systolic diameter (LVESD; 35.2 ± 7.52 mm); 5-year survival in Cluster 1, hereinafter serving as a reference, was 60.9%. Cluster 2 presented with preserved LVEF (55.7 ± 7.82%) but showed the largest mitral valve effective regurgitant orifice area (0.623 ± 0.360 cm2) and highest systolic pulmonary artery pressures (68.4 ± 16.2 mmHg); 5-year survival ranged at 43.7% (P-value: 0.032). Cluster 3 was characterized by impaired LVEF (31.0 ± 10.4%) and enlarged LVESD (53.2 ± 10.9 mm); 5-year survival was reduced to 38.3% (P-value: <0.001). The poorest 5-year survival (23.8%; P-value: <0.001) was observed in Cluster 4 with biatrial dilatation (left atrial volume: 312 ± 113 mL; right atrial area: 46.0 ± 8.83 cm2) although LVEF was only slightly reduced (51.5 ± 11.0%). Importantly, the prognostic significance of ML-derived phenotypes was externally confirmed.CONCLUSION:ML-enabled phenotyping captures the complexity of extra-mitral valve cardiac damage, which does not necessarily occur in a sequential fashion. This novel phenotyping approach can refine risk stratification in patients undergoing MV TEER in the future.

ZusammenfassungDie koronare Herzerkrankung ist die häufigste Herzerkrankung bei Frauen und Männern. Geschlechtsspezifische Unterschiede in der Symptomatik, der Prognose und der Behandlung bei Patienten mit koronarer Herzerkrankung wurden bereits in zahlreichen Studien untersucht. Frauen sind älter, besitzen mehr Komorbiditäten, beklagen eher atypische Symptome, suchen später ärztliche Hilfe auf und werden weniger leitliniengerecht behandelt. In dem Artikel sollen geschlechtsspezifische Unterschiede bei Patienten mit akutem und chronischem Koronarsyndrom zusammengefasst werden.

Background: The influence of diabetes mellitus (DM) on recurrent in-stent restenosis (ISR) of femoropopliteal arteries remains understudied. We investigated whether DM has an impact on recurrent restenosis after femoropopliteal stenting in patients included in the dRug-coatEd balloon angioPlasty for femoropopliteAl In-stent Restenosis (REPAIR) cooperation. Patients and methods: The REPAIR cooperation pooled the patient-level data from 3 randomized trials in which patients with ISR of femoropopliteal arteries received either drug-coated balloon (DCB) or plain balloon angioplasty. For this analysis, patients were divided in two groups based on whether they had or had not a DM diagnosis at the time of enrollment. The primary outcome was target lesion revascularization (TLR). The main secondary outcome was recurrent ISR. Other outcomes of interest were death, Rutherford class improvement and ankle-brachial index at follow-up. Results: 256 patients (DM, n=99 vs. non-DM, n=157) with 12-month follow-up were included in the analysis. Compared to non-DM patients, DM patients displayed no difference in terms of TLR [adjusted hazard ratio (95% Confidence intervals): 0.96 (0.55, 1.69), p=0.89] and recurrent ISR [1.04 (0.61, 1.77), p=0.88], whilst mortality was higher [9.38 (1.06, 83.11), p=0.044]. There were no differences between groups with respect to other secondary outcomes. The percutaneous treatment with DCB as compared to plain balloon angioplasty significantly reduced the risk of TLR and recurrent ISR without an excess risk of death irrespective of DM (p for interaction >= 0.70). Conclusions: In patients with femoropopliteal ISR, diabetes has a neutral effect on the risk of recurrence, but increases mortality at 12-month follow-up. DCB as compared to plain balloon angioplasty is associated with superior efficacy without trade-off in safety, regardless of diabetes.

We retrospectively analyzed patient records of all patients with a history of internal mammarian artery (IMA) coronary bypass undergoing coronary angiography at two cardiovascular centers between January 1st 1999 and December 31st 2019. A total of 11,929 coronary angiographies with or without percutaneous coronary intervention were carried out in 3921 patients. Our analysis revealed 82 (2%) patients with documented subclavian artery stenosis. Of these, 8 (10%) patients were classified as having mild, 18 (22%) moderate, and 56 (68%) severe subclavian artery stenosis. In 7 (9%) patients with subclavian artery stenosis, angiography revealed occlusion of the IMA graft. 26 (32%) patients with severe subclavian artery stenosis underwent endovascular or surgical revasculararization of the subclavian artery. In this retrospective multicenter study, subclavian artery stenosis was a relevant finding in patients with an internal mammarian artery coronary bypass graft undergoing coronary angiography. The development of dedicated algorithms for screening and ischemia evaluation in affected individuals may improve treatment of this potentially underdiagnosed and undertreated condition.

Background: The influence of diabetes mellitus (DM) on recurrent in-stent restenosis (ISR) of femoropopliteal arteries remains understudied. We investigated whether DM has an impact on recurrent restenosis after femoropopliteal stenting in patients included in the dRug-coatEd balloon angioPlasty for femoropopliteAl In-stent Restenosis (REPAIR) cooperation. Patients and methods: The REPAIR cooperation pooled the patient-level data from 3 randomized trials in which patients with ISR of femoropopliteal arteries received either drug-coated balloon (DCB) or plain balloon angioplasty. For this analysis, patients were divided in two groups based on whether they had or had not a DM diagnosis at the time of enrollment. The primary outcome was target lesion revascularization (TLR). The main secondary outcome was recurrent ISR. Other outcomes of interest were death, Rutherford class improvement and ankle-brachial index at follow-up. Results: 256 patients (DM, n=99 vs. non-DM, n=157) with 12-month follow-up were included in the analysis. Compared to non-DM patients, DM patients displayed no difference in terms of TLR [adjusted hazard ratio (95% Confidence intervals): 0.96 (0.55, 1.69), p=0.89] and recurrent ISR [1.04 (0.61, 1.77), p=0.88], whilst mortality was higher [9.38 (1.06, 83.11), p=0.044]. There were no differences between groups with respect to other secondary outcomes. The percutaneous treatment with DCB as compared to plain balloon angioplasty significantly reduced the risk of TLR and recurrent ISR without an excess risk of death irrespective of DM (p for interaction ≥0.70). Conclusions: In patients with femoropopliteal ISR, diabetes has a neutral effect on the risk of recurrence, but increases mortality at 12-month follow-up. DCB as compared to plain balloon angioplasty is associated with superior efficacy without trade-off in safety, regardless of diabetes.

INTRODUCTION: Transcatheter tricuspid valve repair (TTVR) for high-grade regurgitation (TR) is emerging as a viable option, but defining procedure-related clinical success is challenging, as considerable reduction is not possible in all patients with massive or torrential TR. This study compared clinical outcomes of edge-to-edge TTVR, in patients with residual severe vs moderate-or-less TR. Methods: Eligible patients had chronic symptomatic functional TR despite diuretic therapy, and were deemed inoperable by the local Heart Team. TR was assessed by the current five-grade classification. Efficacy and safety outcomes were compared at baseline and 6 months, with follow-up between January 2021 and May 2022. Results: Forty-three patients had ≥severe (III/V) functional TR, 65% presenting with massive (IV/V) and 14% with torrential (V/V) TR. Mean age was 81.8±4.9 years, with 10.8±6.3% STS-Score. The primary efficacy endpoint of at least one-grade TR reduction was recorded in 91% of all patients, with no device related complications.Residual severe TR (STR subgroup) was present in 15 patients, while 20 (MTR subgroup) had moderate-or-less (≤II/V). By 6 months, 4 patients died, 4 patients had no TR reduction, and MACE rate was 18.6%. Improvement in initial NYHA class III/IV occurred in 61% of STR and 77% of MTR patients. KCCQ Score increased by 17±10.6 pts. (p<0.001) vs 21±11.8 (p<0.001), and six-minute walk test by 69.6±48.7 meters (p<0.001) vs 74.2±63 (p<0.001). Renal and liver function equally improved in both groups [GFR 50±16ml/min/1,73m 2 to 57.8±20.4 (p=0.012) vs 57.4±18.5 to 65.5±21.2 (p=0.002); AST 27.5±9.3U/L to 22.9±7.3 (p=0.039) vs 37.2±25.6 to 26.8±7.3 (p=0.069)]. CONCLUSIONS: Although TTVR should always aim for trace to mild TR, considerable reduction is not always possible. This study indicates that even one-grade TR reduction can significantly impact quality of life, functional capacity and multiorgan involvement, similarly in STR and MTR patients.

Coronary heart disease is the most common heart disease in women and men. Gender-specific differences in symptoms, prognosis and treatment in patients with coronary heart disease have already been investigated in numerous studies. Women are older, have more comorbidities, complain of atypical symptoms, seek medical help later and are less likely treated guideline-directed. The article aims to summarize gender differences in patients with acute and chronic coronary syndrome.

BACKGROUND:Percutaneous repair for severe tricuspid regurgitation (TR) is emerging as a viable option, but patient selection is challenging and predetermined by comorbidities. This study evaluated mid-term outcomes of transcatheter tricuspid valve repair (TTVR) in very sick inoperable patients and explored the concept of risk-based therapeutic futility.METHODS:TTVR patients treated in our centre were prospectively assigned to prohibitive-risk (PR) and high-risk (HR) subgroups, based on Society of Thoracic Surgeons (STS) Score, frailty indices, and major organ system compromise. Efficacy and safety outcomes were compared at baseline, 30 days, and 6 months.RESULTS:Thirty-three patients (mean age 81.9 ± 5.1 years) completed follow-up from May 2021 to March 2022: 18 PR (mean STS Score 15.5 ± 7%) and 15 HR (mean STS Score 6.4 ± 1.7%). The primary efficacy end point of at least 1 grade of TR reduction by 30 days was recorded in 93.9% of all patients, with no device-related adverse events. Improvement in initial New York Heart Association functional class III/IV occurred in 74% of PR and 93% of HR patients. Six-minute walk test increased by 81 ± 43.6 metres (P < 0.001) and 85.8 ± 47.9 metres (P < 0.001), respectively. Renal function tests improved by 15% (P = 0.048) and 7% (P = 0.050), while liver enzymes decreased by 18% (P = 0.020) and 28% (P = 0.052). Right ventricular systolic function increased in both subgroups by at least 24% (P < 0.001). Six-month mortality was 12.1%, with 6 hospitalisations for acute heart failure.CONCLUSIONS:TR reduction significantly affected quality of life, functional capacity, cardiac remodelling, and multiorgan involvement similarly in PR and HR patients. TTVR is feasible in very sick symptomatic patients, regardless of predicted risk.

Abstract Background Percutaneous tricuspid valve (TV) repair for tricuspid regurgitation (TR) is arising as a viable treatment option in high-risk patients and can lead to symptom control an improvement in quality of life (QoL). Newest devices have greatly increased safety and efficacy of interventional TR therapy. However, as with any emerging medical procedure, safety aspects need to be considered and procedural risks gradually reduced. Case summary We present the case of an 87-year-old woman with massive TR despite successful percutaneous mitral valve repair. The patient was turned down for surgery and eventually underwent percutaneous TV repair using the TriClip™ (Abbott Medical) device. Significant TR reduction with sustained procedural success at 30-day follow-up were associated with functional and clinical improvement. Transthoracic echocardiographic guidance of the procedure, thanks to excellent parasternal TV visualization, is highlighted, while the complex anatomy of the TV is pointed out. Discussion Tricuspid regurgitation is an individual predictor of morbidity but frequently found in elderly patients who are deemed very high risk for surgical treatment. This case underscores the use of modern interventional techniques and devices for addressing TR and improving QoL, whether as a stand-alone procedure or as part of complete interventional therapy of the atrioventricular valves.

We retrospectively analyzed all endovascular procedures of infrapopliteal arterial lesions (n = 383) performed in 270 patients at our institution between December 2008 and January 2018. The overall technical success rate was 97% and yielded 98% for stenoses (n = 214) and 95% for occlusions (n = 169). Trans-Atlantic Inter-Society Consensus (TASC II) classification had no impact on success rates (TASC A + B vs C + D; 96.5% vs 96.9%, p = 0.837). Freedom from clinically driven target lesion revascularization (TLR) after 6 and 12 months was 88.3% and 77.2%. TLR was comparable for TASC A to C lesions and no difference was observed comparing groups of moderately complex TASC A/B lesions and more complex TASC C/D lesions (TASC A + B vs C + D; 78.5% vs 74.2%, p = 0.457). Freedom from TLR was significantly lower in very complex TASC D lesions (TASC A + B + C vs D; 79.7% vs 42.5%, p < 0.001). Multivariate analysis identified TASC D lesions (hazard ratio D/A: 1.5; overall p = 0.002), Fontaine class III and IV (hazard ratio III or IV/IIa or IIb: 2.4; p = 0.041), and occlusive lesions (hazard ratio occlusion/stenosis: 2.4; p = 0.026) as predictors for TLR. In conclusion, endovascular therapy for infrapopliteal artery disease was safe and accompanied with a promising long-term outcome.

Background: Taking a medical history and performing a physical examination represent basic medical skills. However, numerous national and international studies show that medical students and physicians-to-be demonstrate substantial deficiencies in the proper examination of individual organ systems. Aim: The objective of this study was to conduct a randomized controlled pilot study to see if, in the context of a bedside clinical examination course in internal medicine, an additional app-based blended-learning strategy resulted in (a) higher satisfaction, better self-assessments by students when rating their history-taking skills (b1) and their ability to perform physical examinations (b2), as well as (c) higher multiple-choice test scores at the end of the course, when compared to a traditional teaching strategy. Methods: Within the scope of a bedside course teaching the techniques of clinical examination, 26 students out of a total of 335 students enrolled in the 2012 summer semester and 2012/2013 winter semester were randomly assigned to two groups of the same size. Thirteen students were in an intervention group (IG) with pre- and post-material for studying via an app-based blended-learning tool, and another 13 students were in a control group (CG) with the usual pre- and post-material (handouts). The IG was given an app specifically created for the history-taking and physical exam course, an application program for smartphones enabling them to view course material directly on the smartphone. The CG received the same information in the form of paper-based notes. Prior to course begin, all of the students filled out a questionnaire on sociodemographic data and took a multiple-choice pretest with questions on anamnesis and physical examination. After completing the course, the students again took a multiple-choice test with questions on anamnesis and physical examination. Results: When compared to the CG, the IG showed significantly more improvement on the multiple-choice tests after taking the clinical examination course (p=0.022). This improvement on the MC tests in the IG significantly correlated with the amount of time spent using the app (Spearman’s rho=0.741, p=0.004). Conclusion: When compared to conventional teaching, an app-based blended-learning approach leads to improvement in test scores, possibly as a result of more intensive preparation for and review of the clinical examination course material.