The save deployment of intra-aortic percutaneous mechanical circulatory support devices is highly dependent on the inner aortic diameter. Finding the anatomically and ethically most suitable animal model for performance testing of new pMCS devices remains challenging. For this study, an ovine model using adult ewes of a large framed breed (Swiss White Alpine Sheep) was developed to test safety, reliability, and biocompatibility of catheter-mounted mechanical support devices placed in the descending thoracic aorta. Following the drawback of fluctuating aortic diameter and device malfunction in the first four animals, the model was improved by stenting the following animals with an aortic stent. Stenting the animals with an intra-aortic over the balloon stent was found to standardize the experimental set-up and to avoid early termination of the experiment due to non-device related issues.

To describe the incidence, therapy and outcome of traumatic tracheobronchial injuries (TTBI) in trauma patients with multiple injuries derived from the DGU TraumaRegister. We analyzed the data on all patients listed on the TraumaRegister DGU (TR-DGU) in Germany between 2002 and 2015 aged 16 years or older and with an Injury Severity Score (ISS) of ≥ 9. We analyzed the data on 136,389 trauma patients, 561 of whom had suffered tracheobronchial injuries (0.4%). The majority were male (73.4%) and had a mean age of 43.7 years. In total, 84.0% of all TTBI injuries occurred secondary to blunt trauma, caused mainly by accidents (71.2%). TTBI was accompanied by several concomitant thoracic injuries such as pneumo- (41.2%) and hemothorax (23.2%), lacerations (7.8%) and contusions (32.3%) of the lung, as well as multiple rib fractures (29.6%). The severity of injury was classified via the abbreviated injury scale (AIS): 39.3% with AIS = 3, 51.3% with AIS = 4 and 60% with AIS = 5 patients underwent surgical interventions. The mortality of patients with tracheobronchial injuries was higher: 24.6%, versus 13.7% in all patients (control group). This high percentage reflects their generally severe injury burden through concomitant injuries. The incidence of TTBI in this large cohort of trauma patients is very low. However, its high mortality rate emphasizes its importance. Mortality was associated with higher ISS and AIS scores. Higher rates of concomitant injuries were therefore associated with a higher mortality rate. TTBI injuries revealed a higher rate of progression to surgical management, with 35% undergoing surgery within the first 24 h. This excessive mortality rate demonstrates a high overall injury burden in patients with TTBI and high mortality of associated injuries. A surgical intervention’s impact on mortality cannot be assessed in this study, as it would need to be investigated in a case-matched study.

Objectives: Despite the defensive mechanisms of the upper respiratory tract to deter substances from entering the lung, small aerosols can pass almost unhindered to the alveoli, potentially resulting in pathological reactions but also a possibility to deliver therapeutics. To test small particles and liquids for their pathological potential and also determine the molecular mechanism in the diverse cell types, we developed an alveolar in vitro model that can be used in an aerosol chamber. Moreover, protective substances preventing or attenuating the pathological reaction could be screened for with this model and cellular uptake of therapeutics can be tested.

Aims:Improved mitral valve leaflet coaptation with consecutive reduction of mitral regurgitation (MR) is a central goal of percutaneous mitral valve repair (PMVR) with the MitraClip® system. As influences of PMVR on mitral valve geometry have been suggested before, we examined the effect of the procedure on mitral annular size in relation to procedural outcome.Methods and results:Geometry of the mitral valve annulus was evaluated in 183 patients undergoing PMVR using echocardiography before and after the procedure and at follow-up. Mitral valve annular anterior-posterior (ap) diameter decreased from 34.0 ± 4.3 to 31.3 ± 4.9 mm (P < 0.001), and medio-lateral (ml) diameter from 33.2 ± 4.8 to 32.4 ± 4.9 mm (P < 0.001). Accordingly, we observed an increase in MV leaflet coaptation after PMVR. The reduction of mitral valve ap diameter showed a significant inverse correlation with residual MR. Importantly, the reduction of mitral valve ap diameter persisted at follow-up (31.3 ± 4.9 mm post PMVR, 28.4 ± 5.3 mm at follow-up).Conclusion:This study demonstrates mechanical approximation of both mitral valve annulus edges with improved mitral valve annular coaptation by PMVR using the MitraClip® system, which correlates with residual MR in patients with MR.

BackgroundPercutaneous edge‐to‐edge mitral valve repair (PMVR) has become an established treatment option for mitral regurgitation in patients not eligible for surgical repair. Currently, most procedures are performed under general anesthesia (GA). An increasing number of centers, however, are performing the procedure under deep sedation (DS). Here, we compared patients undergoing PMVR with GA or DS. Methods and ResultsA total of 271 consecutive patients underwent PMVR at our institution between May 2014 and December 2016. Seventy‐two procedures were performed under GA and 199 procedures under DS. We observed that in the DS group, doses of propofol (743±228 mg for GA versus 369±230 mg for DS, P<0.001) and norepinephrine (1.1±1.6 mg for GA versus 0.2±0.3 mg for DS, P<0.001) were significantly lower. Procedure time, fluoroscopy time, and dose area product were significantly higher in the GA group. There was no significant difference between GA and DS with respect to overall bleeding complications, postinterventional pneumonia (4% for GA versus 5% for DS), or C‐reactive protein levels (361±351 nmol/L for GA versus 278±239 nmol/L for DS). Significantly fewer patients with DS needed a postinterventional stay in the intensive care unit (96% for GA versus 19% for DS, P<0.001). Importantly, there was no significant difference between DS and GA regarding intrahospital or 6‐month mortality. ConclusionsDS for PMVR is safe and feasible. No disadvantages with respect to procedural outcome or complications in comparison to GA were observed. Applying DS may simplify the PMVR procedure.

"Percutaneous Edge-to-Edge Mitral Valve Repair (PMVR) in a Patient with Barlow’s Disease, an Implanted Atrial Septal Defect (ASD) Occluder Device, and a Left Ventricular Assist Device (LVAD)." Structural Heart, 2(5), pp. 469–470

Background: The possibility of weaning from implantable left ventricular assist devices is excellent treatment alternative for end-stage heart failure patients. This is a feasible possibility especially for patients suffering from end-stage heart failure due to myocarditis.

BACKGROUND:The objective of this study was to evaluate the outcome of left ventricular assist device (LVAD) implantation after initial extracorporeal life support (ECLS) in patients with cardiogenic shock and the incidence of post implantation right ventricular failure.METHODS & RESULTS:All patients on ECLS therapy for cardiogenic shock prior to LVAD implantation (n = 15) between October 2011 and January 2014 were analyzed. Baseline patient characteristics, as well as detailed pre-operative treatment and postoperative outcome data were collected retrospectively. At time of admission to our unit all patients were classified INTERMACS II or higher (12 [80%] INTERMACS I). Improvement to INTERMACS III temporary cardiac support (TCS) at time of LVAD implantation was successful in 14 patients (93.3%). End-organ function recovered during ECLS support. No patient needed ongoing ECLS or additional right ventricular support after LVAD implantation. Both in-hospital and 30-day mortality was 6.7% (n = 1). The median duration of LVAD support was 687.9 ± 374.5 days. At the end of the study (follow-up 810.7 +/- 338.9 days), 13 (86.7%) patients were alive. The majority of patients (10 [66.7%]) remained on LVAD support. Transplantation could be performed in 1 (6.7%) patient, 2 (13.3%) patients could be successfully weaned.CONCLUSION:LVAD implantation in ECLS patients leads to improvement of INTERMACS level to INTERMACS III TCS status. Excellent mid-term survival comparable to true INTERMACS III-IV patients could be shown. ECLS prior to LVAD as a bridge-to-bridge therapy may help to lower mortality in primarily unstable patients.

OBJECTIVE/BACKGROUND:Aortic elongation has not yet been considered as a potential risk factor for Stanford type B dissection (TBD). The role of both aortic elongation and dilatation in patients with TBD was evaluated. METHODS:The aortic morphology of a healthy control group (n = 236) and patients with TBD (n = 96) was retrospectively examined using three dimensional computed tomography imaging. Curved multiplanar reformats were used to examine aortic diameters at defined landmarks and aortic segment lengths. RESULTS:Diameters at all landmarks were significantly larger in the TBD group. The greatest diameter difference (56%) was measured in dissected descending aortas (p < .001). The segment with the most considerable difference between the study groups with regard to elongation was the non-dissected aortic arch of patients with TBD (36%; p < .001). Elongation in the aortic arch was accompanied by a diameter increase of 21% (p < .001). In receiver-operating curve analysis, the area under the curve was .85 for the diameter and .86 for the length of the aortic arch. CONCLUSIONS:In addition to dilatation, aortic arch elongation is associated with the development of TBD. The diameter and length of the non-dissected aortic arch may be predictive for TBD and may possibly be used for risk assessment in the future. This study provides the basis for further prospective evaluation of these parameters.

Presently, a new era of drug-eluting stents is continuing to improve late adverse effects such as thrombosis after coronary stent implantation in atherosclerotic vessels. The application of gene expression–modulating stents releasing specific small interfering RNAs (siRNAs) or messenger RNAs (mRNAs) to the vascular wall might have the potential to improve the regeneration of the vessel wall and to inhibit adverse effects as a new promising therapeutic strategy. Different poly (lactic-co-glycolic acid) (PLGA) resomers for their ability as an siRNA delivery carrier against intercellular adhesion molecule (ICAM)-1 with a depot effect were tested. Biodegradability, hemocompatibility, and high cell viability were found in all PLGAs. We generated PLGA coatings with incorporated siRNA that were able to transfect EA.hy926 and human vascular endothelial cells. Transfected EA.hy926 showed significant siICAM-1 knockdown. Furthermore, co-transfection of siRNA and enhanced green fluorescent protein (eGFP) mRNA led to the expression of eGFP as well as to the siRNA transfection. Using our PLGA and siRNA multilayers, we reached high transfection efficiencies in EA.hy926 cells until day six and long-lasting transfection until day 20. Our results indicate that siRNA and mRNA nanoparticles incorporated in PLGA films have the potential for the modulation of gene expression after stent implantation to achieve accelerated regeneration of endothelial cells and to reduce the risk of restenosis.

HomeCirculation: Heart FailureVol. 10, No. 5Percutaneous Mitral Valve Edge-to-Edge Repair Assisted by Hemodynamic Support Devices Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBPercutaneous Mitral Valve Edge-to-Edge Repair Assisted by Hemodynamic Support DevicesA Case Series of Bailout Procedures Peter Seizer, MD, David Schibilsky, MD, Reinhard Sauter, MD, Jürgen Schreieck, MD, Henning Lausberg, MD, Tobias Walker, MD, Meinrad Gawaz, MD, Harald F. Langer, MD and Christian Schlensak, MD Peter SeizerPeter Seizer From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , David SchibilskyDavid Schibilsky From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Reinhard SauterReinhard Sauter From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Jürgen SchreieckJürgen Schreieck From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Henning LausbergHenning Lausberg From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Tobias WalkerTobias Walker From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Meinrad GawazMeinrad Gawaz From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. , Harald F. LangerHarald F. Langer From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. and Christian SchlensakChristian Schlensak From the University Hospital, Department of Cardiology and Cardiovascular Medicine (P.S., R.S., J.S., M.G., H.F.L.) and University Hospital, Department of Cardiovascular and Thoracic Surgery (D.S., H.L., T.W., C.S.), Eberhard Karls University of Tuebingen, Germany. Originally published10 May 2017https://doi.org/10.1161/CIRCHEARTFAILURE.117.004051Circulation: Heart Failure. 2017;10:e004051IntroductionPercutaneous edge-to-edge mitral valve repair (PMVR) using the MitraClip system (Abbott Vascular) is an effective treatment option beyond medical therapy for patients with mitral regurgitation, who are not eligible for cardiac surgery.1 Previously, it was reported that patients with severely impaired left ventricular ejection function (<20%) may have similar benefits from the procedure as patients included in the EVEREST trial (Endovascular Valve Edge-to-Edge Repair Study).2 Hemodynamic support devices can be an option in critically ill patients, such as patients in cardiogenic shock, although their use is a matter of debate.3 Up to now, there is to the best of our knowledge a single report about a PMVR procedure facilitated by a hemodynamic support device.4In this case series, we report 12 patients undergoing PMVR using 6 different hemodynamic support devices: intra-aortic balloon pump (n=3), extracorporeal life support system (Cardiohelp, Maquet, n=7), or Impella 2.5/CP/RP/5.0 (n=5; Figure [A-C]). In some patients, support with more than 1 device was necessary. Successful clip deployment was possible with all the different support strategies. To exemplify the use of a hemodynamic support device during a PMVR procedure, a patient experiencing highly reduced left ventricular function and severe functional mitral regurgitation developed cardiogenic shock. An Impella 5.0 was implanted using a transaxillary approach (Figure [A and D]). The device could be visualized by transesophageal echocardiography in close proximity to the mitral valve leaflets (Figure [E and F]). Nevertheless, we were able to achieve sufficient transesophageal echocardiography views for safe grasping, and after implantation of 2 clips, the severe mitral regurgitation could be significantly reduced to MR I°. In conclusion, PMVR supported by hemodynamic support devices is feasible and safe. Overall, as expected, we observed a rather high adverse event rate 30 days after PMVR accounting for the severity of the underlying pathologies and severe comorbidities in this very high-risk patient collective (Table). Importantly, no procedure-related complication occurred. Future in-depth studies will now have to further challenge the use of hemodynamic support devices in high-risk patients undergoing PMVR.Table 1. Baseline Characteristics and Clinical Parameters of Each Patient Undergoing Percutaneous Mitral Valve RepairPatientsSexAge, yNYHAEuro Score (%)CADLVF (%)Cardiogenic ShockDeviceApproachDevice Time, dMR PreMR PostNo. of ClipsEvents at Day 30HemolysisBleedingDeath at Day 301m60414.52130+IABPF3412ARF−−−2m48435.63320+IABPF8424VT, ARF−−+3m78488.07120+Impella CP→ECLSF2–>5411ARF, DIC+SPH+4m52428.46125+IABP–>ECLSF1–>293–40–12PCG+−+5m58421.62CS19−Impella 5.0A. axilla-ris12412HIT, D+IH−6f74472.98050+Impella RP–>ECLSF1–>1641–22ALF, ARF+−+7m64451.59220+ECLSF30412ARF, Sepsis, ARDS+LGIB−8m73311.98CS20−Impella 5.0A. axilla-ris r.9433D+−−9m84422318+Impella 2.5F13–411ARF+−−10m6647.54120+ECLSF11411Sepsis, D+−−11f64415.16232+ECLSF9433Sepsis, HIT ALF ARF, VT+LGIB, SICB+12m66437.92CS20+ECLSF10422ARF+SICB+Values are given as absolute numbers. ALF indicates acute liver failure; ARDS, acute respiratory distress syndrome; ARF, acute renal failure; CAD, coronary artery disease; CS, coronary sclerosis; D, destination therapy (left ventricular assist device); DIC, disseminated intravascular coagulation; ECLS, extracorporeal life support; f, female; F, femoral approach; HIT, heparin-induced thrombocytopenia; IABP, intra-aortic balloon pump; IH, intrathoracic hematoma; m, male; LGIB, lower gastrointestinal bleeding; LVF, left ventricular ejection fraction; MR, mitral regurgitation; NYHA, New York Heart Association; PCG, persistent cardiogenic shock; SICB, severe intracranial bleeding; SPH, severe pulmonary hemorrhage; and VT, ventricular tachycardia.Download figureDownload PowerPointFigure. A–C, Fluoroscopic periprocedural images of the percutaneous edge-to-edge mitral valve repair procedure using an Impella continuous flow device (A, indicated by *), an intra-aortic balloon pump (B, indicated by #), or an extracorporeal life support system (C, indicated by §). The arrow indicates the implanted clips. D–G, Images of transesophageal echocardiography (TEE) during percutaneous edge-to-edge mitral valve repair using the Impella 5.0 device. E and F, Intercommissural (mediolateral) and outflow-tract TEE-view during leaflet grasping. Impella continuous flow device indicated by *, clip indicated by the arrow. D and G, mitral regurgitation was significantly reduced after deployment of 2 clips.Sources of FundingThis study was supported by grants from the German Research Foundation (KFO 274), the Volkswagen Foundation (Lichtenberg program), and the German Heart Foundation.DisclosuresDrs Langer and Seizer were reimbursed by Abbott Vascular for training courses in the percutaneous mitral valve repair procedure. The other authors report no conflicts.Footnotes*Drs Seizer and Schibilsky share first authorship.†Drs Langer and Schlensak share senior authorship.Correspondence to Harald Langer, MD, or Peter Seizer, MD, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University of Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail [email protected] or E-mail [email protected]References1. Feldman T, Foster E, Glower DD, Glower DG, Kar S, Rinaldi MJ, Fail PS, Smalling RW, Siegel R, Rose GA, Engeron E, Loghin C, Trento A, Skipper ER, Fudge T, Letsou GV, Massaro JM, Mauri L; EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation.N Engl J Med. 2011; 364:1395–1406. doi: 10.1056/NEJMoa1009355.CrossrefMedlineGoogle Scholar2. Franzen O, van der Heyden J, Baldus S, Schlüter M, Schillinger W, Butter C, Hoffmann R, Corti R, Pedrazzini G, Swaans MJ, Neuss M, Rudolph V, Sürder D, Grünenfelder J, Eulenburg C, Reichenspurner H, Meinertz T, Auricchio A. MitraClip® therapy in patients with end-stage systolic heart failure.Eur J Heart Fail. 2011; 13:569–576. doi: 10.1093/eurjhf/hfr029.CrossrefMedlineGoogle Scholar3. Schibilsky D, Kruger T, Lausberg HF, Eisenlohr C, Haller C, Nemeth A, Schibilsky B, Haeberle H, Rosenberger P, Walker T, Schlensak C. Impella 5.0 as a second-line mechanical circulatory support strategy after extracorporeal life support.Artif Organs. 2016; 40:909–916. doi: 10.1111/aor.12804.CrossrefMedlineGoogle Scholar4. Foerst J, Cardenas A, Swank G. Safety of MitraClip implant in the unstable patient: feasibility of concomitant left ventricular support device.JACCCardiovasc Interv. 2016; 9:e71–e72. doi: 10.1016/j.jcin.2015.12.275.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nersesian G, Lewin D, Schoenrath F, Solowjowa N, Kukucka M, Falk V, Klein C, Potapov E and Unbehaun A (2021) Percutaneous mitral valve repair assisted by a catheter‐based circulatory support device in a heart transplant patient, Journal of Cardiac Surgery, 10.1111/jocs.15802, 36:10, (3905-3909), Online publication date: 1-Oct-2021. Villablanca P, Nona P, Lemor A, Qintar M, O'Neill B, Lee J, Frisoli T, Wang D, Eng M and O'Neill W (2021) Mechanical Circulatory Support in Cardiogenic Shock due to Structural Heart Disease, Interventional Cardiology Clinics, 10.1016/j.iccl.2020.12.007, 10:2, (221-234), Online publication date: 1-Apr-2021. Belluschi I, Denti P, Buzzatti N, Melisurgo G, Ajello S, Ancona M, Bertoglio L, Stella S, Agricola E, Alfieri O, Castiglioni A, De Bonis M and Scandroglio A (2021) Complicated Bi-Pella Support: Acute Mitral Regurgitation and Bailout MitraClip Repair, Structural Heart, 10.1080/24748706.2020.1852355, 5:1, (99-100), Online publication date: 1-Jan-2021. Schibilsky D, Takatani S, Schibilsky B, Graf T, da Silva D, Wendel H, Avci-Adali M and Schlensak C (2020) Hemocompatibility of new magnetically-levitated centrifugal pump technology compared to the CentriMag adult pump, Scientific Reports, 10.1038/s41598-020-78709-0, 10:1, Online publication date: 1-Dec-2020. Jorbenadze R, Krüger T, Walker T, Schreieck J, Seizer P, Schlensak C and Langer H (2018) Percutaneous Edge-to-Edge Mitral Valve Repair (PMVR) in a Patient with Barlow's Disease, an Implanted Atrial Septal Defect (ASD) Occluder Device, and a Left Ventricular Assist Device (LVAD), Structural Heart, 10.1080/24748706.2018.1456706, 2:5, (469-470), Online publication date: 1-Sep-2018. May 2017Vol 10, Issue 5 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.117.004051PMID: 28490430 Manuscript receivedMarch 13, 2017Manuscript acceptedApril 12, 2017Originally publishedMay 10, 2017 Keywordsdevices for heart failuremitral valvecomorbiditypercutaneous mitral valve repairpercutaneous left ventricular assist devicePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsHeart FailureValvular Heart Disease

In the last decades, many efforts have been made to counteract adverse effects after stenting atherosclerotic coronary arteries. A breakthrough in better vascular wall regeneration was noted in the new era of drug-eluting stents. A novel personalized approach is the development of gene-eluting stents promising an alteration in gene expression involved in regeneration. We investigated a coating system consisting of the polymer atelocollagen (ATCOL) and a specific small interfering RNA (siRNA) for intercellular adhesion molecule-1 (ICAM-1) found on the surface of defective endothelial cells (ECs). We demonstrated very high cell viability, in which EA. hy926 grew on 0.008% or 0.032% ATCOL layers. Additionally, hemocompatibility assays proved the biocompatibility of this coating. The highest transfection efficiency with EA. hy926 was achieved with 5 mu g siRNA immobilized in ATCOL after 2 days. The release of fluorescent-labeled siRNA was about 9 days. Longterm knockdown of ICAM-1 was analyzed by flow cytometry, revealing that the coating with 0.008% ATCOL and 5 mg siICAM-1 provoked gene silencing up to 8 days. 50-RNA ligase-mediated rapid amplification of cDNA ends PCR (RLM-RACE-PCR) demonstrated the specificity of our established ATCOL gene-silencing coating, meaning that our coating is well suited for further investigations in in vivo studies. Herein, we would like to demonstrate that our ATCOL is well-suited for better artery wall regeneration after stent implantation.

HomeCirculation: Heart FailureVol. 10, No. 4Percutaneous Transfemoral Tricuspid Valve Edge-to-Edge Repair Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBPercutaneous Transfemoral Tricuspid Valve Edge-to-Edge RepairA Case Series Karin Müller, MD, Rezo Jorbenadze, MD, Tobias Walker, MD, Robert Schüler, MD, Christoph Hammerstingl, MD, Christian Schlensak, MD, Meinrad Gawaz, MD, Harald F. Langer, MD and Peter Seizer, MD Karin MüllerKarin Müller From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Rezo JorbenadzeRezo Jorbenadze From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Tobias WalkerTobias Walker From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Robert SchülerRobert Schüler From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Christoph HammerstinglChristoph Hammerstingl From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Christian SchlensakChristian Schlensak From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Meinrad GawazMeinrad Gawaz From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). , Harald F. LangerHarald F. Langer From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). and Peter SeizerPeter Seizer From the Department of Cardiology and Cardiovascular Medicine (K.M., R.J., M.G., H.F.L., P.S.) and Department of Cardiovascular Surgery (T.W., C.S.), University Hospital, Eberhard Karls University Tuebingen, Germany; and Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany (R.S., C.H.). Originally published4 Apr 2017https://doi.org/10.1161/CIRCHEARTFAILURE.117.003965Circulation: Heart Failure. 2017;10:e003965Recently, transcatheter treatment of the tricuspid valve was reported as an interventional approach for severe tricuspid regurgitation (TR).1 From May 2016 to January 2017, 8 patients underwent percutaneous transfemoral tricuspid valve edge-to-edge repair using the MitraClip system (Abbott Vascular) as recommended by our interdisciplinary heart team. The patient characteristics and procedural data are described in Table. All patients experienced severe TR and had relevant comorbidities. In 6 out of 8 patients, at least one clip could be placed; in 5 out of these 6 patients, TR could be reduced at least by 1.5 grades. In 4 out of 8 patients, we applied intracardiac echocardiography (ICE) as an additional imaging modality because visualization of the tricuspid valve is a crucial point in this procedure. In the following paragraphs, we describe one of these cases supported by ICE.Table. Baseline Characteristics and Clinical Parameters of Each Patient Undergoing Percutaneous Tricuspid Valve RepairPatientsSexAge, yNYHAEuro ScoreFrailtyCADLVF, %RVF, +/−TAPSEPM/ICDTR PreTR PostCoaptation Gap, mmPAPsys, mm Hg, PrePAPsys, mm Hg, PostClips ImplantedICE, +/−1M81415.3+260−13−41–22105371+2M80414.6-+345+21−33740380−3M7937.6+135−13VVI-ICD44840260−4F7935.1+160+22−42021282−5F83327.1+340−18VVI-PM31051351+6M89427.0+140−10VVI-PM42117222+7F83444.5+360−10−441242421−8M59433.6+060−13−42–3642403+Values are given as absolute numbers. CAD indicates coronary artery disease; ICD, implantable cardioverter-defibrillator, ICE, intracardiac echocardiography; LVF, left ventricular ejection fraction; MC, MitraClip; NYHA, New York Heart Association; PAPsys, systolic pulmonary arterial pressure measured in echocardiography; PM, pacemaker, RVF, right ventricular ejection fraction (− indicates impaired RVF and + indicates normal RVF); and TR, tricuspid regurgitation.A 78-year-old patient presented with right heart failure symptoms caused by severe TR (Figure [A]). Four years ago, percutaneous edge-to-edge mitral valve repair was performed with reduction of MR to grade I–II (Figure [A]). Intraprocedural transesophageal echocardiography revealed that the main TR regurgitation jet was located between the anterior and the septal leaflet of the tricuspid valve (Figure [A and B]). The clip was positioned underneath the tricuspid valve plane, then rotation and position of the clip were adjusted using transesophageal echocardiography (Figure [C and D]). Because imaging of leaflet insertion and adjustment of clip alignment by transesophageal echocardiography guidance was not sufficient, we decided to perform additional ICE. An ICE probe (ViewFlex Plus ICE Catheter; St Jude Medical) was advanced into the right atrium (Figure [D and E]). Using ICE guidance, we could visualize that sufficient leaflet material was caught by the clip (Figure [F through H]). Interestingly, we generated a double orifice–like morphology (Figure [I]). When we deployed the clip (Figure [J]), we achieved a strong reduction of TR as confirmed by ICE and conventional transesophageal echocardiography (Figure [K and L]).Download figureDownload PowerPointFigure. Images of intracardiac echocardiography (ICE), fluoroscopy, and transesophageal echocardiography (TOE) during percutaneous edge-to-edge tricuspid valve repair. A and B, TOE revealed severe tricuspid valve regurgitation between the anterior and the septal leaflet (A, 4-chamber view and B, transgastric view). C and D, TOE view and fluoroscopic anteroposterior (AP) view verifying correct clip rotation, ICE catheter indicated by →. E, ICE confirmed severe tricuspid regurgitation. F–H, View provided by the ICE catheter to support guidance of the grasping maneuver and verify leaflet insertion. I, Double orifice after clip deployment as visualized by TOE. J, Fluoroscopic AP view after clip deployment. K, View provided by ICE showing residual TR after clip deployment. L, Residual mild TR in TOE 4-chamber view. A indicates anterior leaflet; c, clip; P, posterior leaflet; and S, septal leaflet. #Artifact; *Clip arms.In conclusion, edge-to-edge tricuspid valve repair is a novel option for patients with severe TR not eligible for conventional surgery. There are, however, limitations to this approach such as limited visualization of the valve, feasibility of the procedure as determined by the underlying pathology, and lack of profound experience. Future studies would have to further scrutinize the value of the edge-to-edge tricuspid valve repair.Sources of FundingThis study was supported by grants from the German research foundation (KFO 274) and the Volkswagen foundation (Lichtenberg program).DisclosuresDr Langer and Dr Seizer were reimbursed by Abbott Vascular for training courses in the percutaneous mitral valve repair procedure. The other authors report no conflicts.Footnotes*Drs Langer and Seizer share senior authorship of this article.Correspondence to Peter Seizer, MD, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail [email protected] or Harald F. Langer, MD, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail [email protected]References1. Hammerstingl C, Schueler R, Malasa M, Werner N, Nickenig G. Transcatheter treatment of severe tricuspid regurgitation with the MitraClip system.Eur Heart J. 2016; 37:849–853.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Ranard L, Vahl T, Chung C, Sadri S, Khalique O, Hamid N, Nazif T, George I, Ng V, Patel A, Rezende C, Reisman M, Latib A, Hausleiter J, Sorajja P, Bapat V, Tang G, Davidson C, Zahr F, Makkar R, Fam N, Granada J, Leon M, Hahn R and Kodali S (2022) Impact of inferior vena cava entry characteristics on tricuspid annular access during transcatheter interventions, Catheterization and Cardiovascular Interventions, 10.1002/ccd.30048, 99:4, (1268-1276), Online publication date: 1-Mar-2022. Akhtar Y, Walker W, Shakur U, Smith G, Husnain S and Adigun S (2021) Clinical outcomes of percutaneous debulking of tricuspid valve endocarditis in intravenous drug users, Catheterization and Cardiovascular Interventions, 10.1002/ccd.29584, 97:6, (1290-1295), Online publication date: 1-May-2021. Jorbenadze R, Schreieck J, Barthel C, Seizer P, Schlensak C, Gawaz M, Patzelt J and Langer H (2018) Percutaneous Edge-to-Edge Mitral Valve Repair Using the New MitraClip XTR System, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2018.04.005, 11:12, (e93-e95), Online publication date: 1-Jun-2018. April 2017Vol 10, Issue 4 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.117.003965PMID: 28377441 Manuscript receivedFebruary 20, 2017Manuscript acceptedMarch 1, 2017Originally publishedApril 4, 2017 Keywordsheart failurecomorbidityechocardiography, transesophagealmitral valvevalve insufficiencytricuspidPDF download Advertisement SubjectsTreatmentValvular Heart Disease

BackgroundSuccessful percutaneous mitral valve repair (PMVR) in patients with severe mitral regurgitation (MR) causes changes in hemodynamics. Echocardiographic calculation of cardiac output (CO) has not been evaluated in the setting of PMVR, so far. Here we evaluated hemodynamics before and after PMVR with the MitraClip system using pulmonary artery catheterization, transthoracic (TTE) and transesophageal (TEE) echocardiography.Methods101 patients with severe MR not eligible for conventional surgery underwent PMVR. Hemodynamic parameters were determined during and after the intervention. We evaluated changes in CO and pulmonary artery systolic pressure before and after PMVR. CO was determined with invasive parameters using the Fick method (COi) and by a combination of TTE and TEE (COe).ResultsAll patients had successful clip implantation, which was associated with increased COi (from 4.6±1.4l/min to 5.4±1.6l/min, p<0.001). Furthermore, pulmonary artery systolic pressure (PASP) showed a significant decrease after PMVR (47.6±16.1 before, 44.7±15.5mmHg after, p=0.01). In accordance with invasive measurements, COe increased significantly (COe from 4.3±1.7l/min to 4.8±1.7l/min, p=0.003). Comparing both methods to calculate CO, we observed good agreement between COi and COe using Bland Altman plots.ConclusionsCO increased significantly after PMVR as determined by echocardiography based and invasive calculation of hemodynamics during PMVR. COe shows good agreement with COi before and after the intervention and, thus, represents a potential non-invasive method to determine CO in patients with MR not accessible by conventional surgery.

Background: Extracorporeal life support (ECLS) is an established treatment option for patient in refractory cardiogenic shock. This study describes the outcome of patients who treated with ECLS in cardiogenic shock at remote hospitals.

Recently, we described a percutaneous mitral valve edge-to-edge repair (PMVR) procedure in a patient using both transesophageal echocardiography (TOE) and intracardiac echocardiography (ICE).1 In that patient, however, central steps of PMVR were guided primarily by TOE. Advantages of intracardiac echocardiography are avoidance of TOE and thus general anesthesia. The procedure can be performed in a conscious patient. Accordingly, the need for catecholamines, the risk of hypotension, prolonged periods of weaning from mechanical ventilation, and postinterventional delirium are reduced. Although in theory the use of left atrial ICE is sufficient to guide PMVR, ICE has not been used as the only imaging modality to guide PMVR because of disadvantages such as the lack of 3-dimensional (3D) vision with X-plane views and particularly the lack of experience using ICE for PMVR. Here, we report a PMVR procedure in a patient with functional mitral regurgitation (MR) using ICE because TOE guidance was not possible. A 78-year-old patient presented with decompensated heart failure with MR grade IV (Figure, A and B). He had a history of repeated hospitalizations for heart failure caused by ischemic cardiomyopathy with severely reduced left ventricular function. An internal cardioverter-defibrillator had been implanted because he had repeated ventricular arrhythmias. As a result of severe comorbidities, a decision for PMVR was made by our interdisciplinary heart team. TOE was not possible (even with endoscopic guidance) because …

OBJECTIVES This study sought to evaluate a ventilation maneuver to facilitate percutaneous edge-to-edge mitral valve repair (PMVR) and its effects on heart geometry.BACKGROUND In patients with challenging anatomy, the application of PMVR is limited, potentially resulting in insufficient reduction of mitral regurgitation (MR) or clip detachment. Under general anesthesia, however, ventilation maneuvers can be used to facilitate PMVR.METHODS A total of 50 consecutive patients undergoing PMVR were included. During mechanical ventilation, different levels of positive end-expiratory pressure (PEEP) were applied, and parameters of heart geometry were assessed using transesophageal echocardiography.RESULTS We found that increased PEEP results in elevated central venous pressure. Specifically, central venous pressure increased from 14.0 +/- 6.5 mm Hg (PEEP 3 mm Hg) to 19.3 +/- 5.9 mm Hg (PEEP 20 mm Hg; p < 0.001). As a consequence, the reduced pre-load resulted in reduction of the left ventricular end-systolic diameter from 43.8 +/- 10.7mm (PEEP 3 mm Hg) to 39.9 +/- 11.0 mm (PEEP 20 mm Hg; p < 0.001), mitral valve annulus anterior-posterior diameter from 32.4 +/- 4.3 mm (PEEP 3 mm Hg) to 30.5 +/- 4.4 mm (PEEP 20 mm Hg; p < 0.001), and the medio-lateral diameter from 35.4 +/- 4.2 mm to 34.1 +/- 3.9 mm (p = 0.002). In parallel, we observed a significant increase in leaflet coaptation length from 3.0 +/- 0.8 mm (PEEP 3 mm Hg) to 5.4 +/- 1.1 mm (PEEP 20 mm Hg; p < 0.001). The increase in coaptation length was more pronounced in MR with functional or mixed genesis. Importantly, a coaptation length > 4.9 mm at PEEP of 10 mm Hg resulted in a significant reduction of PMVR procedure time (152 +/- 49 min to 116 +/- 26 min; p = 0.05).CONCLUSIONS In this study, we describe a novel ventilation maneuver improving mitral valve coaptation length during the PMVR procedure, which facilitates clip positioning. Our observations could help to improve PMVR therapy and could make nonsurgical candidates accessible to PMVR therapy, particularly in challenging cases with functional MR. (J Am Coll Cardiol Intv 2016; 9: 151-9) (C) 2016 by the American College of Cardiology Foundation.