Abstract Background Interventional left atrial appendage occlusion (LAAO) is an alternative therapeutic strategy equivalent to non-vitamin K antagonist oral anticoagulation (OAC) in preventing thromboembolism (TE) for non-valvular atrial fibrillation (AF) patients with contraindications to OAC. However, patients with prior stroke are at relevant higher risk for TE than general patient populations. These patients are often prone to multimorbidity, are at high risk for bleeding, and may well benefit from LAAO. Purpose To investigate the performance of LAAO in secondary prevention after prior stroke versus patients without history of stroke and to reveal any potential differences in effectiveness and safety. Methods Data from multicenter German LAARGE was used, which is a prospective, non-randomized registry on clinical reality of LAAO with different standard commercial devices. Effectiveness was primarily assessed by the combined absence of all-cause death or non-fatal stroke within 365 days after the procedure, and secondarily by the absence of transient ischemic attack (TIA) or systemic embolism. Safety was assessed with data documenting adverse events during index hospitalization or follow-up. Results 638 patients from 38 centers were consecutively included. 137 patients had a history of stroke (21.5%) and 501 patients had none. Stroke patients had a significantly pronounced cardiovascular comorbidity: CHA2DS2-VASc score 5.9+1.3 vs. 4.1+1.4 and HAS-BLED score 4.6+1.0 vs. 3.7+1.1, respectively (each p<0.001). A high procedural success (98.5 vs. 97.4%, p=NS) was accompanied by low periprocedural MACCE or major complication rates (0% vs. 0.6 and 4.4 vs. 4.0%, respectively; each p=NS). Primary effectiveness outcome measure was not statistically different between both groups on follow-up (freedom from all-cause death or non-fatal stroke: 87.8 vs. 87.7%), while TIA (0 vs. 0.5%), systemic embolism (0.9 vs. 0%) as well as severe bleeding events (0 vs. 0.7%; each p=NS) were extremely rare. Conclusions Patients with history of stroke, though showing significantly pronounced multimorbidity, demonstrated a similar effectiveness and safety profile for LAAO as compared to patients without prior stroke. LAAO could serve as a feasible alternative to OAC in this selected group of high-risk AF patients with contraindications to standard care.All-cause death or non-fatal stroke (KM)

BACKGROUND:Takotsubo Syndrome (TTS) is an acute reversible left ventricular dysfunction. Recently published studies have highlighted a similar mortality rate as acute coronary syndrome (ACS). We compared the impact of gender differences on the outcome of TTS patients as compared to ACS patient. DESIGN AND METHODS:We included a collective of 138 patients TTS between 2003 and 2016 at our institution. Patients were divided according to their gender into two groups (Males n=21, 15% and females, n=117, 85%). They were compared with a cohort of 300 patients with a diagnosis of ACS. RESULTS:On the acute phase, in male patients with TTS, a treatment with inotropic was more often required (33.3 vs. 11.5%, P<0.01), were more susceptible to cardiogenic shock (28.6 vs. 12.5%, P<0.04). Concerning the long-term prognosis after the acute event, male patients had higher all-cause mortality over long-term follow-up. A Kaplan-Meier analysis indicated that the mortality of male patients with TTS was significantly higher compared to male patients with ACS (log-rank <0.01), while there was no significant difference between female patients with TTS and ACS (log-rank =0.60, P=0.45). In a multivariate cox regression analysis, male gender (HR 2.7, 95% CI: 1.1-6.5, P=0.02) GFR <60 ml/min (HR 2.8, 95% CI: 1.2-6.0, P=0.01) and history of cancer (HR 3.6, 95% CI 1.4-9.3, P<0.01) were independent predictors of 5-year mortality. CONCLUSIONS:Considerable evidence suggests that TTS compared to ACS implicates more significant clinical short-term events on male patients and it may be associated with poorer long-term prognosis.

Die Lungenarterienembolie (LE) ist eine häufig auftretende Komplikation bei kritisch kranken Patienten. Das gleichzeitige Auftreten von LE und lebensbedrohlichen Blutungen ist ein therapeutisches Dilemma. Für diese Patientenpopulation stellen Vena-cava-Filter (VCF) eine therapeutische Option dar. Der Angel®-Katheter (Bio2 Medical Inc. San Antonio, TX, USA) ist ein neuartiger temporärer VCF, der bettseitig ohne Durchleuchtung implantiert wird.

PurposePulmonary embolism (PE) is a frequently occurring complication in critically ill patients. Simultaneous occurrence of PE and life-threatening bleeding, may render medical anticoagulation impossible. For these patients, inferior vena cava filters (IVCF) present a valuable therapeutic alternative. The Angel® catheter is a novel IVCF that provides temporary protection from PE and is implanted at bedside.The primary objective of the European Angel® catheter registry is to evaluate the safety and efficacy of this IVCF.Material and methodsThe European Angel® catheter registry is an observational, multi-centre registry. Patients from four countries and eight sites that have undergone Angel® catheter implantation between March 2013 and February 2017 were enrolled.ResultsA total of 114 critically ill patients were included. The main indication for implantation was a high-risk for PE in combination with contraindications for anticoagulation (69.3%). One clinically non-significant PE (0.9%) occurred in a patient with an indwelling Angel® catheter. No cases of catheter associated serious complications were observed.ConclusionData shows that the Angel® catheter is a safe and effective approach to overcome the acute phase of critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

Aim Takotsubo syndrome (TTS) patients have a higher mortality rate than the general population. Our study was conducted to determine the short- and long-term outcome of TTS patients associated with a significantly compromised mitral annular plane systolic excursion (MAPSE) on hospital admission. Methods and results Our institutional database constituted a collective of 53 patients diagnosed with TTS between 2003 and 2016. The patients were classified into two groups based on the MAPSE, with those presenting with an MAPSE <1 cm on admission categorized into one group (n = 20, 38%) and those presenting with MAPSE ≥1 cm (n = 33, 62%) categorized into another group. Preliminary results indicated that patients with an MAPSE < 1 cm had a greater risk of developing thromboembolic events. The long-term mortality was significantly higher in TTS patients with an MAPSE < 1 cm. In the multivariate Cox regression analysis, cardiogenic shock (hazard ratio 3.5; 95% confidence interval: 1.2-10.7; P = 0.02) and MAPSE < 1 cm (hazard ratio 5.1; 95% confidence interval: 1.3-19.2; P = 0.01) figured as independent predictors of the mortality. Conclusion Although the short-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were as similar as without reduced MAPSE, the long-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were significantly higher. There is an urgent need for randomized trials, which could help define uniform clinical management strategies for high-risk TTS patients.

Background and aimTakotsubo cardiomyopathy (TC) is an important differential diagnosis of coronary artery disease (CAD), mimicking acute coronary syndrome in clinical symptoms, biomarker profiles and ST-elevation in ECG. Absence of occlusive coronary disease is an essential criterion distinguishing both diseases. The aim of the study was to explore the influence of co-existing incidental CAD on poorer clinical outcomes and all-cause mortality in TC.Design, methods and resultsOur mono-centric study cohort constituted 114 consecutive patients diagnosed with TC between 2003 and 2015. The primary endpoint was the all-cause mortality. Additionally, we compared the incidence of thromboembolic events, life-threatening arrhythmias, cardiogenic shock and in-hospital death. There was no significant difference in gender distribution or mean age in both groups. Patients diagnosed with a co-existing CAD (n = 22), had a more pronounced cardiovascular risk profile. The all-cause mortality among patients with co-existing CAD after a 2-year follow-up was higher than those diagnosed with lone TC (22.7 vs. 5.4 %, P = 0.07). In a multivariate cox regression analysis CAD (HR 3.5, 95 %CI 1.0-11.6; P = 0.04), LVEF ≤ 35% (HR 3.8, 95% CI 0.0-0.6, P = 0.01) and cardiogenic shock (HR 3.8, 95% CI 1.2-11.3; P = 0.01) were independent predictors of the primary endpoint.ConclusionOur study reveals that co-existing CAD impairs the outcome in patients with TC. The diagnostic work-up for TC should therefore not necessarily hinge on ruling out CAD.

Ein 49-jähriger Patient stellte sich mit zunehmender Dyspnoe und Hautausschlag vor. Bei ambulant erworbener Pneumonie wurde eine antibiotische Therapie eingeleitet. Es kam zu einer raschen Verschlechterung der respiratorischen Situation sowie zum Bild eines Waterhouse-Friderichsen-Syndroms mit beginnenden Nekrosen der Zehen. Es bestätigte sich eine Infektion mit Capnocytophaga canimorsus, die durch einen anamnestisch initial unerwähnten Hundebiss übertragen wurde. In Anbetracht des fulminanten Verlaufs sowie des hohen Risikos einer operativen Versorgung der ubiquitären Nekrosen aller Gliedmaßen entschieden wir uns gemeinsam mit den Angehörigen für eine Deeskalation der Therapie. Der Patient verstarb 14 Tage nach der Aufnahme.

Zusammenfassung Hintergrund Die Lungenarterienembolie (LE) ist eine häufig auftretende Komplikation bei kritisch kranken Patienten. Das gleichzeitige Auftreten von LE und lebensbedrohlichen Blutungen ist ein therapeutisches Dilemma. Für diese Patientenpopulation stellen Vena-cava-Filter (VCF) eine therapeutische Option dar. Der Angel®-Katheter (Bio2 Medical Inc. San Antonio, TX, USA) ist ein neuartiger temporärer VCF, der bettseitig ohne Durchleuchtung implantiert wird. Methodik Das europäische Angel®-Katheter-Register ist eine multizentrische Beobachtungsstudie. In unserer Substudie wurden Patienten aus 3 deutschen Kliniken und 4 Intensivstationen eingeschlossen, die zwischen Februar 2016 und Dezember 2016 eine Angel®-Katheter-Implantation erhalten haben. Ergebnisse Es wurden 23 kritisch kranke Patienten (68 ± 9 Jahre, 43 % männlich) in die Studie eingeschlossen. Die Hauptindikation für die Implantation waren eine manifeste LE oder Patienten mit einem erhöhten Risiko für eine LE, in Kombination mit einer Kontraindikation für eine prophylaktische oder therapeutische Antikoagulation aufgrund eines erhöhten Risikos für eine Blutung (81 %) oder einer aktiven Blutung (13 %). In 100 % der Fälle gelang die Implantation problemlos. Während des Implantationszeitraums traten keine LE auf, wohingegen größere Thromben über 20 mm in 5 % der Fälle in der Kavographie festgestellt wurden. Die Entfernung des Filters gelang problemlos in 100 % der Fälle, während es in 3 % der Fälle zu einer Filterdislokation kam. Diskussion Die deutschen Daten aus dem europäischen Angel®-Katheter-Register zeigen, dass die Angel®-Katheter-Implantation eine sichere und effektive Möglichkeit ist, LE bei kritisch kranken Patienten, die eine nachgewiesene LE oder ein hohes Risiko für eine LE haben, zu verhindern, solange eine Antikoagulation kontraindiziert ist.

Background Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. It is still unclear whether sex differences may influence long-term prognosis of TTC patients. The purpose of this study was to determine whether sex differences do influence the short- and long-term outcomes of TTC. Methods and results A total of 114 patients with TTC were admitted to the University Medical Centre Mannheim from January 2003 to September 2015 and entered into the TTC database of the University Medical Centre Mannheim, and retrospectively analyzed. Patients were diagnosed by the Mayo Clinic criteria. All-cause mortality over mean follow-up of 1,529±1,121 days was revealed. Significantly more male patients died within long-term follow-up compared to female TTC patients (log-rank test; P=0.01). Most males died of noncardiac causes. In multivariate Cox regression analysis, the male sex (P=0.02, hazard ratio [HR] 2.8, 95% CI 1.1–7.2), the ejection fraction ≤35% (P=0.01, HR 3.3, 95% CI 1.2–9.2) and glomerular filtration rate <60 mL/min (P<0.01, HR 3.1, 95% CI 1.4–7.0) figured out as independent predictors of the adverse outcome. Conclusion This study shows that males suffering from TTC reveal a higher long-term all-cause mortality rate than females over a 5 year follow-up period.

We report on the case of a 49-year-old man who presented with increasing dyspnea and a skin rash. The community-acquired pneumonia was initially treated with broad spectrum antibiotics. The patient's respiratory condition rapidly worsened and the clinical picture ofWaterhouse-Friderichsen syndrome developed with disseminated intravasal coagulopathy and necrosis of the toes. An infection with Capnocytophaga canimorsus, which had been caused by an initially unmentioned dog bite was confirmed. In view of the fulminant course and the high risk of operative treatment of the ubiquitous necroses in all limbs, a joint decision for deescalation of therapy was made together with relatives. The patient died 14 days after admission to hospital.

BACKGROUND:Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC.METHODS AND RESULTS:Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P  < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison.CONCLUSIONS:The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.