In der interventionellen Kardiologie unterstützen medizinische Fachangestellte, Pflegekräfte, operationstechnisches Assistenzpersonal sowie medizinische Technologinnen und Technologen die Medizinerinnen und Mediziner bei der täglichen Arbeit. Die interventionelle Kardiologie hat sich die letzten 20 Jahre enorm weiterentwickelt. Vielfältige, z. T. hochkomplexe Diagnostik- und interventionelle Behandlungsverfahren erfordern immer besser ausgebildetes Personal im ärztlichen und nichtärztlichen Bereich. Das Weiterbildungscurriculum kardiologische Fachassistenz für interventionelle Kardiologie baut auf dem Basiscurriculum kardiologische Fachassistenz auf und soll eine optimale Ausbildung dieser Berufsgruppe gewährleisten und damit ihre Handlungskompetenzen in der interventionellen Kardiologie deutlich stärken.

BACKGROUND:Ultrasound-guided puncture of the common femoral artery (CFA) is assumed to be more precise than conventional techniques without ultrasound. However, previous comparative studies have shown partly contradictory results with regard to success of ultrasound-guided puncture so that this method is not yet standard in transfemoral cardiac catheterization. AIMS:The PARFEM trial was performed to investigate whether an ultrasound-assisted in-plane technique using a needle guide could improve the precision of CFA puncture. METHODS:The study was conducted in 286 patients undergoing transfemoral cardiac catheterization. Patients were randomized 1:1, and femoral artery puncture was performed either using an ultrasound-guided in-plane technique with fluoroscopic marking of the center of the femoral head or a conventional approach. The primary endpoint was successful puncture of the CFA with the first attempt. In addition, the influence of the examiners' level of experience on puncture results was investigated. RESULTS:Primary successful puncture of the CFA was achieved more frequently in the ultrasound group than in the control group: 79.6% versus 55.6%, odds ratio 3.25 [95% CI: 1.92-5.23], p < 0.001. This favorable effect of ultrasound guidance was independent of the examiners' level of experience. The success rate of ultrasound-guided sheath placement within the CFA was 97.2%, compared to 77.8% in the control group (p < 0.01). CONCLUSIONS:The PARFEM trial demonstrated that in-plane ultrasound guidance can improve the precision of femoral puncture and reduce the occurrence of inadequate sheath placements. The results support the incorporation of this technique into standard practice for guiding transfemoral puncture. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT06065943.

Invasive cardiac output (CO) is measured with the thermodilution (TD) or the indirect Fick method (iFM) in right heart catheterization (RHC). The iFM estimates CO using approximation formulas for oxygen consumption ( V̇ O2), but there are significant discrepancies (> 20 V̇ O2 estimation (iFM-K/-L/-D/-B). Percentage errors were calculated as twice the standard deviation of the difference between two CO methods divided by their means; a cut-off of < 30 V̇ O2 estimation are needed that better reflect today’s patients undergoing RHC.

Intracavitary thrombi are an important differential diagnosis of cardiac masses. Cardiac magnetic resonance imaging (CMR) allows their non-invasive characterization. This case highlights extensive cardiac thrombi detected by CMR as solitary presentation of antiphospholipid syndrome.

Introduction Simulation technology has an established role in teaching technical skills to cardiology fellows, but its impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training, in addition to traditional methods would improve CA image interpretation skills in a heterogeneous group of medical trainees. Methods We prospectively randomized a convenience sample of 105 subjects comprising of medical students ( N = 20), residents ( N = 68) and fellows ( N = 17) from the University of Arizona. Subjects were randomized in a stratified fashion into a simulation training group which received simulation training in addition to didactic teaching ( n = 53) and a control training group which received didactic teaching alone ( n = 52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm. Results Subjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p = 0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p = 0.02 for interaction of training arm and education status. Conclusions Simulation training complements traditional methods to improve CA interpretation skill, with greatest impact on residents. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

BACKGROUND:To prevent complications, uncontrolled movement of the guidewire during a coronary intervention should be avoided. Unintentional withdrawal of the wire can result in the inability to recross a lesion with the risk of myocardial infarction. On the other hand, unintended forward pushing can lead to a coronary perforation. Thus, interventionalists in training should practice keeping the coronary guidewire in a stable position to prevent complications. For this purpose, a skill trainer has been developed, which provides the possibility of unlimited practice outside of the cath lab.The purpose of this study was to assess the effectiveness and the validity of this skills trainer.METHODS:Ten novices and 10 participants with experience in diagnostic catheterization underwent training on the skills trainer consisting of 25 procedures. To assess the efficacy of the training module, the mean score of the first 3 procedures was compared with the final 3 procedures in the novice and the advanced group. To determine the construct validity of the simulator, a group of experts (E; performed >1000 percutaneous coronary interventions) also underwent evaluation on the skills trainer. For each procedure, the change in position of the guidewire as well as the time was determined and combined into a skills score with a maximum of 15 points.RESULTS:The novice and the advanced group improved significantly throughout the training on the simulator (N: 7.1 ± 2.6 to 12.2 ± 2.0, P = 0.007; A: 8.3 ± 2.0 to 13.2 ± 1.0, P = 0.005, Wilcoxon).The experts scored significantly higher than novices or the advanced participants during their first 3 procedures (E: 12.9 ± 1.0; N: 7.1 ± 2.6, P = 0.001; A: 8.3 ± 2.0, P = 0.001; Mann-Whitney U ).CONCLUSIONS:This low-cost task trainer is a valid and effective tool to train adequate balloon/stent exchange while keeping the guidewire in a stable position. Whether the skills acquired on the task trainer can be transferred to procedures performed on patients needs further investigation.

This manual addressing the interventional treatment (part 2) is a recommendation for interventional cardiologists. It displays the latest evidence in interventional cardiology. Each chapter was designed to focus on the everyday practicability and to provide decision support for cardiologists in the daily clinical routine of a catheter laboratory. Despite the practical advice by many experts, this manual cannot replace the medical evaluation of each individual patient and thus an adaptation of the diagnostics or treatment is necessary.

This manual on diagnostic cardiac catheterization (part 1) is a recommendation for application by interventional cardiologists, which reflects the latest evidence in interventional cardiology. Each chapter was designed to focus on the everyday practicability and to provide decision support in the daily clinical routine of the catheter laboratory. Despite the practical advice by many experts, this manual cannot replace the medical evaluation of each individual patient and thus an adaptation of the diagnostics or treatment is necessary.

Dieses Manual zur interventionellen Therapie (Teil 2) ist eine Anwendungsempfehlung für interventionell tätige Ärzte, die den gegenwärtigen Kenntnisstand unter Berücksichtigung neuester Studienergebnisse wiedergibt. Hierzu wurde in den einzelnen Kapiteln speziell auf die Alltagstauglichkeit der Empfehlungen geachtet, sodass dieses Manual jedem interventionell tätigen Kardiologen als Entscheidungshilfe im Herzkatheterlabor dienen soll. Trotz der von vielen Experten eingebrachten praktischen Hinweise kann dieses Manual dennoch nicht die ärztliche Evaluation des individuellen Patienten ersetzen und damit eine Anpassung der Diagnostik bzw. Therapie ersetzen.

Despite TAVR emerging as the gold standard for a broad spectrum of patients, it is associated with serious complications. In this report we present a case, where a TAVR procedure led to a perforation at the aortomitral continuity, discuss the risk factors for the occurrence of perforations and how we decided to treat the patient.

A pericardiocentesis is a procedure associated with potential life-threatening complications, such as liver and lung perforation. A “blind” pericardiocentesis is performed by orientation according to certain anatomic landmarks only. As a safer option, ultrasound can be employed to guide the

From the various mechanical cardiac assist devices and indications available, use of the percutaneous intraventricular Impella CP pump is usually restricted to acute ischemic shock or prophylactic indications in high-risk interventions. In the present study, we investigated clinical usefulness of the Impella CP device in patients with non-ischemic cardiogenic shock as compared to acute ischemia. In this retrospective single-center analysis, patients who received an Impella CP between 2013 and 2017 due to non-ischemic cardiogenic shock were age-matched 2:1 with patients receiving the device due to ischemic cardiogenic shock. Inclusion criteria were therapy refractory hemodynamic instability with severe left ventricular systolic dysfunction and serum lactate >2.0 mmol/l at implantation. Basic clinical data, indications for mechanical ventricular support, and outcome were obtained in all patients with non-ischemic as well as ischemic shock and compared between both groups. Continuous variables are expressed as mean ± standard deviation or median (quartiles). Categorical variables are presented as count and percent. 25 patients had cardiogenic shock due to non-ischemic reasons, and were compared to 50 patients with cardiogenic shock due to acute myocardial infarction. Resuscitation rates before implantation of Impella CP were high (32 vs 42%; P=0.402). At implantation, patients with non-ischemic cardiogenic shock had lower levels of HsTNT (110.65 [57.87–322.1] vs 1610 [450.8–3861.5] pg/ml; P=0.001) and LDH (377 [279–608] vs 616 [371.3–1109] U/I; P=0.007), while age (59±16 vs 61.7±11; P=0.401), GFR (43.5 [33.2–59.7] vs 48 [35.75–69] ml/min; P=0.290), CRP (5.17 [3.27–10.26] vs 10.97 [3.23–17.2] mg/dl; P=0.195), catecholamine-index (30.6 [10.6–116.9] vs 47.6 [11.7–90] μg/kg/min; P=0.663), and serum lactate (2.6 [2.2–5.8] vs 2.9 [1.3–6.6] mg/dl; P=0.424) were comparable between both groups. There was a trend for longer duration of Impella support in the non-ischemic groups (5 [2–7.5] vs 3 [2–5.25] days, P=0.211). Rates of hemodialysis (52 vs 47%; P=0.680) and transition to ECMO (13.6 vs 22.2%; P=0.521) were comparable. No significant difference was found regarding both 30-days survival (48 vs 30%; P=0.126, Figure 1) as well in-hospital mortality (66.7 vs 74%; P=0.512) although there was a trend for better survival in the non-ischemic group. 30-days survival The current results position short-time use of the Impella CP as an alternative in the treatment of patients with cardiogenic shock due to underlying non-ischemic cardiomyopathy and/or complicating additional factors. However, additional studies are needed to test whether these findings can be confirmed in larger patient populations and which subgroups might benefit most from Impella therapy.

Background Long-term data on evolution and clinical impact of myocardial fibrosis in valvular heart disease are scarce. Methods and Results In this 10 years’ extension of a prospective study in patients undergoing conventional aortic valve replacement because of symptomatic severe aortic valve stenosis, the impact of myocardial replacement fibrosis (MRF) on long-term outcome was assessed. Endomyocardial biopsies were acquired during aortic valve replacement in 58 consecutive patients. MRF was graded using the calculated percentage area of fibrosis and patients categorized as severe (n=21), mild (n=15), and no fibrosis (n=22). Echocardiography including strain imaging, as well as cardiovascular magnetic resonance, to assess late gadolinium enhancement was performed at baseline, 1, and 10 years after aortic valve replacement. Death of any cause occurred in 21 patients (38.9%): 3 (14.3%) in the group without MRF, 6 (42.9%) in the mild MRF group, and 12 (63.2%) in the severe MRF group (P=0.006), resulting in the lowest cumulative survival for patients with severe MRF (log-rank P=0.003). In the group without MRF, none died of cardiovascular cause. MRF was found to be an independent predictor of survival (hazard ratio, 1.271; 95% CI, 1.032–1.564; P=0.024). Conclusions This 10-year follow-up study underlines the profound impact of replacement fibrosis with regard to cardiac and all-cause mortality in patients undergoing aortic valve replacement for severe aortic valve stenosis. Integrating cardiovascular magnetic resonance and echocardiographic functional imaging beyond ejection fraction quantification could help in clinical decision making to stratify patient prognosis with regard to myocardial longitudinal function and prevalence of replacement fibrosis.

An incorrect transseptal puncture (TSP) position can lead to difficulties during clip navigation and placement for mitral valve (MV) repair. We investigated the height difference of optimal TSP positions as measured by 2D echo compared to a 3D approach using an investigational Philips EchoNavigator

Background "Blind" pericardiocentesis is the standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable. Under these circumstances, puncture site and needle direction are exclusively oriented according to certain anatomic landmarks. In the literature, different techniques for this "blind" method have been described. Goal of this retrospective study was to compare the potential success and complication rate of 13 simulated puncture directions. Methods Simulated pericardiocentesis was performed in 150 CT scans from patients with moderate to severe pericardial effusions (greater than 1 cm distance between epicardium and pericardium). Thirteen different puncture techniques with varying puncture sites, direction of the puncture, and the angle were compared. A simulated pericardiocentesis was classified as "successful" when the effusion was reached. It was classified as "successful without a complication" when no adjacent structure was penetrated by the simulated puncture (lung, liver, internal thoracic artery, LAD, colon, and stomach). An attempt was declared as "unsuccessful" when the pericardial effusion was not reached at all, or the reached effusion measured less than 0.5 cm between the epicardium and pericardium at the location where the needle entered the pericardium. Results A subxiphoidal puncture technique starting in Larrey's triangle (sternocostal triangle) and directed toward the left midclavicular point with a 30 degrees inclination resulted in the highest success rate (131 of 150 cases = 87%). In parallel the lowest complication rate (7 of 150 = 5%) was found using this technique, as well. In contrast, pericardiocentesis performed using other puncture directions resulted in lower success (66%-85%) and higher complication rates (9%-31%). Conclusion This CT-based simulation study revealed that blind pericardiocentesis guided by anatomical landmarks only is best performed in a subxiphoid approach with a needle direction to the left midclavicular point with a 30 degrees inclination. Nevertheless, injury of adjacent structures occurred frequently (5%) even when applying this puncture technique. Thus, blind pericardiocentesis can be performed with a high success rate and seems adequate to be performed under emergency conditions. However, planned procedures should be performed under image guidance.

are independent predictors of stenosis after hemostasis with 2 Proglide devices in our series.In vitro study showed that the lumen area becomes smaller when using 2 Proglide devices in small vessels.Further studies are needed to evaluate the role of single Proglide closure approach in CFA.