A Comparative Study of 1-Year Postprocedural Outcomes in Transcatheter Mitral Valve Repair in Advanced Primary Mitral Regurgitation: PASCAL vs. MitraClip

Both the MitraClip and PASCAL systems offer transcatheter edge-to-edge repair (TEER) solutions for mitral regurgitation. Evidence indicates a lower technical success rate for TEER in complex degenerative mitral regurgitation (DMR) cases. We conducted a retrospective analysis of patients who underwent transcatheter edge-to-edge therapy for primary mitral regurgitation with advanced anatomy, defined as mitral regurgitation effective regurgitant orifice area (MR-EROA) ≥0.40 cm2 or large flail gap (≥5 mm) or width (≥7 mm) or Barlow's disease, that completed follow-up after 1 year. Our criteria were met by 27 patients treated with PASCAL and 18 with MitraClip. All patients exhibited a significant, equivalent short-term reduction in MR-EROA, mitral regurgitation vena contracta diameter (MR-VCD), regurgitant volume, and clinical status. At 1 year follow-up, reductions in MR-VCD, regurgitant volume, and MR-EROA remained significant for both groups without significant differences between groups. MR-Grade ≤ 1+ was achieved in 18 (66.7%) and 10 (55.6%) patients, respectively. At follow-up, no difference in hospitalization for cardiac decompensation was observed. Overall death was similar in both groups. Our study suggests that both the PASCAL and MitraClip systems significantly reduce mitral regurgitation even in advanced degenerative diseases. Within our limited data, we found no evidence of inferior performance of the PASCAL system.

Cardiac biomarkers as indicators of right ventricular dysfunction and recovery in chronic thromboembolic pulmonary hypertension patients after balloon pulmonary angioplasty therapy - a cardiac magnetic resonance imaging cohort study

Background

In chronic thromboembolic pulmonary hypertension, right heart failure determines outcome. Balloon pulmonary angioplasty therapy allows right heart recovery, which can be monitored by cardiac magnetic resonance imaging. This study evaluates whether cardiac biomarkers (NT-proBNP, MR-proANP, sST2, and PAPP-A) are associated with cardiac magnetic resonance imaging findings prior to and after balloon pulmonary angioplasty therapy.

Methods

This observational cohort study enrolled 22 chronic thromboembolic pulmonary hypertension patients who underwent balloon pulmonary angioplasty therapy and completed a six-month follow-up including cardiac magnetic resonance imaging. Biomarker levels were compared with findings for right heart morphology and function derived from cardiac magnetic resonance imaging.

Results

Pulmonary hemodynamics improved after balloon pulmonary angioplasty therapy [pulmonary vascular resistance: 7.7 (6.0–9.0) vs. 4.7 (3.5–5.5) wood units, p < 0.001; mean pulmonary artery pressure 41 (38–47) vs. 32 (28–37) mmHg, p < 0.001]. Cardiac magnetic resonance imaging findings indicated right heart maladaptation at baseline and recovery after therapy [right ventricular end-diastolic volume 192 (141–229) ml vs. 143 (128–172) ml, p = 0.002; right ventricular end-systolic volume 131 (73–157) ml vs. 77 (61–99) ml (p < 0.001); right ventricular ejection fraction (RVEF) 34 (28–41) % vs. 52 (41–54) %; p < 0.001]. Biomarker level cut-offs [NT-proBNP 347 ng/L (area under the curve (AUC) 0.91), MR-proANP 230 pg/L (AUC 0.78), PAPP-A 14.5 mU/L (AUC 0.81), and sST2 48.0 ng/ml (AUC 0.88)] indicated a RVEF ≤ 35% at baseline. The dynamics of NT-proBNP (rs = −0.79; p < 0.001), MR-proANP (rs = –0.80; p < 0.001), and sST2 (rs = –0.49; p = 0.02) correlated inversely with the improvement in RVEF after therapy. A relative decrease of NT-proBNP < 53% (AUC 0.86) and MR-proANP < 24% (AUC 0.82) indicated a limited RVEF response.

Conclusions

In chronic thromboembolic pulmonary hypertension patients, cardiac magnetic resonance imaging findings illustrate right heart failure and recovery after balloon pulmonary angioplasty therapy. Cardiac biomarker levels correlate with right heart parameters at baseline and their dynamics after therapy.

Identifying Heart Failure in ECG Data With Artificial Intelligence-A Meta-Analysis

Introduction: Electrocardiography (ECG) is a quick and easily accessible method for diagnosis and screening of cardiovascular diseases including heart failure (HF). Artificial intelligence (AI) can be used for semi-automated ECG analysis. The aim of this evaluation was to provide an overview of AI use in HF detection from ECG signals and to perform a meta-analysis of available studies.

Methods and Results: An independent comprehensive search of the PubMed and Google Scholar database was conducted for articles dealing with the ability of AI to predict HF based on ECG signals. Only original articles published in peer-reviewed journals were considered. A total of five reports including 57,027 patients and 579,134 ECG datasets were identified including two sets of patient-level data and three with ECG-based datasets. The AI-processed ECG data yielded areas under the receiver operator characteristics curves between 0.92 and 0.99 to identify HF with higher values in ECG-based datasets. Applying a random-effects model, an sROC of 0.987 was calculated. Using the contingency tables led to diagnostic odds ratios ranging from 3.44 [95% confidence interval (CI) = 3.12–3.76] to 13.61 (95% CI = 13.14–14.08) also with lower values in patient-level datasets. The meta-analysis diagnostic odds ratio was 7.59 (95% CI = 5.85–9.34).

Conclusions: The present meta-analysis confirms the ability of AI to predict HF from standard 12-lead ECG signals underlining the potential of such an approach. The observed overestimation of the diagnostic ability in artificial ECG databases compared to patient-level data stipulate the need for robust prospective studies.

Novel potential diagnostic targets revealed by plasma proteomic analysis in chronic thromboembolic pulmonary hypertension

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with poor outcome if untreated, although it is a curable form of pulmonary hypertension (PH). Successful treatment requires an optimized diagnostic work-up.

Purpose

The aim of this study was to identify non-invasive biomarkers that might serve as new diagnostic parameters in the multifaceted pathophysiology of CTEPH.

Methods

The biomarker profile of 64 CTEPH patients who underwent balloon pulmonary angioplasty (BPA) was analyzed prior to and after therapy and compared with that of a healthy control group (CG1, n=25) at baseline. Proteomes were analyzed by semiquantitative screening based on a proximity extension assay of three high-throughput, multiplex immunoassay panels. Serum levels of a subset of biomarkers identified in the screening were additionally measured by immunochemical methods.

Results

Fifty protein biomarkers were found to differ between CTEPH patients and CG1. Eight biomarkers changed significantly after therapy. The overlap of these two groups revealed six targets that were all upregulated in CTEPH at baseline and modifiable by treatment. In this group of biomarkers, the levels of DCN (decorin), HGF (hepatocyte growth factor), BNP (B-type natriuretic peptide), and PAPP-A (papalysin-1) decreased after therapy, whereas SPON-1 (spondin-1) and MEPE (matrix extracellular phosphoglycoprotein) further increased at follow-up. The differences in these biomarkers in CTEPH as well as the dynamics after therapy were confirmed and quantified in enzyme-linked immunosorbent assays.

Conclusions

This study identified 6 biomarkers that might serve as new diagnostic parameters or constitute new therapeutic targets in CTEPH. Further prospective studies will be necessary to determine the specific pathophysiological role of each marker.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Copeptin as a non-invasive biomarker in chronic thromboembolic pulmonary hypertension

Introduction

Copeptin is the C-terminal fragment of the precursor protein of vasopressin. In acute pulmonary embolism, copeptin has been suggested to be a strong predictor of outcome and to provide additional predictive value to the established cardiac biomarkers high-sensitivity cardiac troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP). Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in about 5% of patients who survive acute pulmonary embolism. Individualized risk stratification remains a challenge in the work-up of CTEPH patients.

Purpose

The current study investigated whether copeptin has the potential to aid the stratification of patients who have experienced pulmonary embolism and CTEPH patients. We examined the baseline (BL) levels and dynamics of copeptin during therapy in CTEPH patients who underwent balloon pulmonary angioplasty (BPA) or pulmonary endarterectomy (PEA). Moreover, the study compared copeptin levels between patients with or without therapy response.

Methods

The study included a total of 125 CTEPH patients scheduled for treatment. A total of 78 underwent staged BPA and 64 underwent PEA. In accordance with recent studies from our group, therapy success was defined as a decrease in meanPAP ≥25% and PVR ≥35% or a normalization below the thresholds defining pulmonary hypertension. Blood samples were collected at BL, prior to each BPA session in the BPA cohort, and at follow-up (FU) 6 months after BPA or 12 months after PEA. Copeptin was measured in thawed serum aliquots by an immunochemical method.

Results

The 78 patients in the BPA cohort underwent a mean of 6 BPA procedures each; there were a total of 413 interventions. The hemodynamic clinical and functional status the CTEPH patients improved after BPA and PEA therapy: meanPAP (BL: 43±9 mmHg vs. FU: 27±9 mmHg; p&lt;0.001); PVR (BL: 7.6±3.4 WU vs. FU: 3.8±2.0 WU; p&lt;0.001); RAP (BL: 7.9±5.8 mmHg vs. FU: 5.4±2.7 mmHg; p&lt;0.001); WHO functional class [BL: I:0 / II:25 / III:80 / IV:20 vs. FU: I:56 / II:57 / III:10 / IV:2]; 6-minute-walk distance (BL: 405±99 m vs. FU: 456±112 m; p&lt;0.001).

The median serum levels of copeptin [BL 7.7 (4.6–14.2) pmol/L vs. FU 6.3 (3.9–12.5); p=0.009] and NT-proBNP [BL: 811 (157–1857) ng/L vs. FU: 142 (72–335) ng/L p&lt;0.001] decreased significantly after therapy. The copeptin levels did not correlate with hemodynamics at BL: PVR (rrs=0.02; p=0.79) and meanPAP (rrs=0.03; p=0.75). The copeptin levels at BL (AUC=0.61) and the relative change (AUC=0.53) did not predict the endpoint of therapy response.

Conclusions

Copeptin levels are elevated in CTEPH patients compared with normal values in the literature. Although copeptin is known to provide additional value in the context of risk stratification in acute pulmonary embolism, it failed to provide additional diagnostic benefit in CTEPH in the current study.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Mid-regional pro-atrial natriuretic peptide and copeptin as indicators of disease severity and therapy response in CTEPH

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) leads to right heart failure. Pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) restore pulmonary haemodynamics and allow cardiac recovery. This study examined the relationship of copeptin and mid-regional pro-atrial natriuretic peptide (MR-proANP) levels to disease severity and therapy response.

METHODS

This observational cohort study included 125 patients (55 PEA/70 BPA) who underwent treatment and completed a 6-/12-month follow-up. Biomarkers, measured at baseline, prior to every BPA and at follow-up, were compared to 1) severe disease at baseline (right atrial pressure (RAP) ≥8 mmHg and cardiac index ≤2.4 L·min-1·m-2) and 2) optimal therapy response (no persistent pulmonary hypertension combined with a normalised RAP (mean PAP ≤25 mmHg, pulmonary vascular resistance (PVR) ≤3 WU and RAP ≤6 mmHg) or a reduction in mean PAP ≥25%, PVR ≥35% and RAP ≥25%).

RESULTS

Severely diseased patients had higher levels of MR-proANP (320 (246-527) pmol·L-1 versus 133 (82-215) pmol·L-1; p=0.001) and copeptin (12.7 (7.3-20.6) pmol·L-1 versus 6.8 (4.4-12.8) pmol·L-1; p=0.015) at baseline than the rest of the cohort. At baseline, MR-proANP (area under the curve (AUC) 0.91; cut-off value 227 pmol·L-1; OR 56, 95% CI 6.9-454.3) and copeptin (AUC 0.70; cut-off value 10.9 pmol·L-1; OR 1.5, 95% CI 1.2-1.9) identified severely diseased patients. After PEA/BPA, levels of MR-proANP (99 (58-145) pmol·L-1; p<0.001) and copeptin (6.3 (3.7-12.6) pmol·L-1; p=0.009) decreased and indicated optimal therapy response (MR-proANP <123 pmol·L-1 (AUC 0.70) and copeptin <10.1 pmol·L-1 (AUC 0.58)).

CONCLUSION

MR-proANP and copeptin levels are affected in CTEPH and decrease after therapy. MR-proANP identifies a severe disease status and optimal therapy response.

Pregnancy-associated plasma protein A - a new indicator of pulmonary vascular remodeling in chronic thromboembolic pulmonary hypertension?

Background

In chronic thromboembolic pulmonary hypertension (CTEPH) impaired pulmonary hemodynamics lead to right heart failure. Natriuretic peptides reflect hemodynamic disease severity. Pregnancy-associated plasma protein-A (PAPP-A) might address another aspect of CTEPH - chronic tissue injury and inflammation. This study assessed dynamics of PAPP-A in CTEPH patients who undergo therapy with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA).

Methods

The study included a total of 125 CTEPH patients scheduled for treatment (55 PEA/ 70 BPA) and a control group of 58 patients with pulmonary hypertension other than CTEPH. Biomarker measurement was performed at baseline and follow-up in the CTEPH cohort, prior to each BPA in the BPA cohort and once in the control group.

Results

The median PAPP-A level was slightly higher (p = 0.05) in CTEPH patients [13.8 (11.0–18.6) mU/L], than in the control group [12.6 (8.6–16.5) mU/L], without a difference between the BPA and PEA group (p = 0.437) and without a correlation to mean pulmonary artery pressure (p = 0.188), pulmonary vascular resistance (p = 0.893), cardiac index (p = 0.821) and right atrial pressure (p = 0.596). PEA and BPA therapy decreased the mean pulmonary artery pressure (p < 0.001) and pulmonary vascular resistance (p < 0.001) and improved the WHO-functional-class (baseline: I:0/II:25/III:80/IV:20 vs. follow-up: I:55/II:58/III:10/IV:2). PAPP-A levels decreased after PEA [13.5 (9.5–17.5) vs. 11.3 (9.8–13.6) mU/L; p = 0.003) and BPA treatment [14.3 (11.2–18.9) vs. 11.1 (9.7–13.3) mU/L; p < 0.001). The decrease of PAPP-A levels is delayed in comparison to N-terminal pro-B-type natriuretic peptide.

Conclusion

PAPP-A is overexpressed in CTEPH and decrease significantly after surgical or interventional therapy, however without association to hemodynamics. Further investigation is needed to define the underlying mechanism of PAPP-A expression and changes after therapy in CTEPH.

[The Influence of Laparoscopic Fundoplication on Reflux-Associated Cough]

Introduction: The gastrooesophageal reflux disease (GERD) is a possible cause of chronic cough. The laparoscopic fundoplication is well established in the treatment of GERD. In a retrospective study, the effectivity of this operation on the GERD associated cough was examined and possible preoperative predictive factors concerning the post-surgical therapy effect were characterized. Patients and Methods: 85 patients after laparoscopic fundoplication due to GERD treated with proton pump inhibitors without (RS-H: n = 31) or with associated cough (RS+H: n = 54) were evaluated in a three-month follow-up by data analysis regarding an indication point score from typical symptoms as well as findings (gastroscopy, histology, 24-hour oesophagus pH-metry). Results: For the leading symptoms of heartburn and regurgitation a complete freedom from complaints was reached with 98.8 % of all patients postal-surgically. In the group RS+H 70.4 % of the patients were free of cough after 3 months, other 22.2 % with significant improvement and 7.4 % with unchanged irritant cough. Higher values of the typical reflux symptoms and a therapy resistance to proton pump inhibitors (PPI) were clearly seen in the RS-H patients. The RS+H patients showed less reflux complaints with lower PPI resistance, frequent allergies as well as significantly more often an acid or bitter taste and hoarseness. After further subdivision of the RS+H patients into the subgroups RS>H (mainly reflux, n = 31) and H>RS (mainly cough), the lowest values for heartburn, regurgitation and PPI resistance were found in subgroup H>RS. Diagnostics did not show any significiant differences between the groups although a trend could be seen towards fewer duodenogastric bile reflux, larger hiatus hernias and higher DeMeester scores in RS+H and H>RS. Also smokers, non-allergic asthmatics and polyallergic sufferers with cough profited from the intervention. Conclusion: Patients with reflux-associated respiratory symptoms present an own entity with good PPI therapy response to heartburn, but not to cough. They should be considered more often for surgery. Since the cough symptoms in more than two-thirds of appropriately selected patients disappear in a short time after surgery, laparoscopic antireflux surgery should also be considered from pneumological aspects. There are no individual predictors for the success of antireflux surgery, only the sum of all relevant individual case history and clinical criteria, as they are combined in the used score, can provide a reliable indication for surgery.

[Results of TcTUs-optimized radioiodine therapy in multifocal and disseminated autonomy]

AIM

The presented study prospectively evaluates the efficacy of optimized radioiodine therapy in patients (pts) with multifocal (MFA) and disseminated (DISA) autonomy. The target dose was related to the total thyroid volume and was increased in moderate and nonlinear increments from 150 to 300 Gy dependent on the pretherapeutic Tc-99m pertechnetate thyroid uptake under suppression (TcTUs). Patients with focal autonomy were treated with a target dose independent of TcTUs and were used as control group.

METHODS

The data of 641 pts (518 women, 123 men) were evaluated, 466 pts with MFA or DISA and 175 pts with focal autonomy. In pts with MFA and DISA the target dose was increased in four steps: TcTUs < 3%: 150 Gy, > 3-6%: 200 Gy, > 6-12%: 250 Gy and > 12%: 300 Gy. In pts with focal autonomy a fixed target dose of 300 or 400 Gy was applied. The radioactivity to be administered was calculated using a modified Marinelli formula. The follow-up examination was performed at the earliest after four, on average after eight months. Normalization of TSH was the only criterion for successful therapy.

RESULTS

The success rate in pts with latent or manifest hyperthyroidism in focal autonomy was 91.5%, therapy was not successful in 5.1% and hypothyroidism occurred in 3.4%. The average success rate in pts with MFA and DISA was 91.5%, therapy failed in 7.5% and a very low rate of 1% with hypothyroidism was seen.

CONCLUSION

The presented optimized therapy concept with calculated, nonlinear increase of the target dose according to the TcTUs-level guaranteed even in MFA and DISA a high success rate comparable to that in focal autonomy along with a very low rate of hypothyroidism.

[Paradoxical effect of radioiodine therapy in functional thyroid autonomy and mild immunothyropathy]

AIM

To examine all cases with Graves' disease after radioiodine therapy of autonomously functioning thyroid tissue (AFFT) in order to find the cause.

METHODS

We retrospectively studied 1428 pts who were treated between 11/93 and 3/97 with radioiodine for AFTT and who underwent at least one control examination.

RESULTS

15 (1.1%) of all pts developed Graves' disease 8.4 (4-13) months after radioiodine therapy. There was no direct suggestion of Graves' disease (TRAK negative, no endocrine ophthalmopathy) in any pt at the time of radioiodine therapy. More detailed analysis of anamnestic data, however, revealed evidence that immunothyropathy predated radioiodine therapy in 11 of the 15 pts. Paradoxical effects of radioiodine therapy manifested as an increase in immunothyropathy in 14 pts, a deterioration in metabolism in 11 pts and a first occurrence of endocrine ophthalmopathy in 5 pts.

CONCLUSION

Exacerbation of preexisting, functional primarily insignificant immunothyropathia is held responsible in most cases for the observed paradoxical effects after radioiodine therapy, resulting in radiation-induced manifest Graves' disease; however no therapeutical consequences are recommended.

Nutritional supplementation of nucleotides restores opioid CNS-mediated phenomena in mice

Previous experiments have demonstrated that suppression of immune function by either cyclosporin A or by a nucleotide free (NF) diet results in attenuation of morphine withdrawal symptoms in mice suggesting that immune status impacts CNS opioid-related phenomena. The present study elaborates on these initial findings by examining the effects of repletion of the NF diet with nucleotides or their precursors on opiate withdrawal. Female Balb/c mice were divided into six groups: a control group (C) given a standard lab chow diet and five experimental groups each given one of the following diets: a nucleotide free diet (NF); the NF supplemented with 0.25% RNA (NFR 0.25); the NF supplemented with 2.5% RNA (NFR 2.5) the NF supplemented with 0.06% uracil (NFU 0.06); the NF supplemented with 0.6% uracil (NFU 0.6). The mice were made morphine dependent by subcutaneous implantation of morphine pellets. Seventy-two hours after morphine pellet implantation, withdrawal was precipitated with naloxone (2 mg/kg). The mice were then observed and two indicators of withdrawal scored: jumping and diarrhea. The NF, NFR 0.25, NFR 2.5 and NFU 0.06 groups demonstrated significantly attenuation of the withdrawal signs relative to control animals. The NFU 0.6 group, however, had withdrawal scores restored to near control levels for both jumping and diarrhea. This suggests that nucleotides, particularly uracil, may play an important role in the immune-to-brain signaling pathway.

[Arthrodesis as an alternative in infected knee arthroplasty]

There is reported on ten arthrodeses after infected knee arthroplasty, nine of these were completely built through after 4.4 months on the average. The fixation and stabilization of the arthrodeses were carried out by means of fixateur externe.

Suppression of opiate withdrawal by cyclosporin A and dietary modification

It has been demonstrated in a murine model that a defined diet (Purina Basal Diet 5755) has immunosuppressive effects similar to cyclosporin A (CsA). It was also shown that CsA treatment in opiate dependent rats can attenuate the severity of opiate withdrawal. In this study, an opiate dependence model was established in Balb/c mice to assess the effects of the 5755 diet and CsA on morphine withdrawal - a CNS mediated phenomenon. Three groups of mice were used; a chow-fed control group (Purina 5008), a chow fed CsA treated group, and a group maintained on the 5755 diet. Morphine dependence was established by subcutaneous implantation of a 100 mg morphine base pellet under ether anesthesia. Seventy-two hours after pellet implantation, withdrawal was precipitated by a single injection of the opiate antagonist naloxone (2 mg/kg ip). Two indicators of withdrawal were assessed; jumping and diarrhea. The data demonstrated that both CsA and the 5755 diet resulted in significant attenuation of withdrawal symptoms with the 5755 diet being the most effective of the two. These findings suggest that immune modulation elicited by the 5755 diet and CsA treatment has a direct impact on the CNS opioid function.

[Operative treatment of lateral hyperpressure syndrome of the patella]

The lateral hyperpressure syndrome of the patella according to Ficat is characterized as a main cause of chondropathia patellae. Symptoms and course as well as roentgenology of this syndrome are illustrated. The logical method of treatment of this syndrome is the lateral release-operation according to Viernstein and Weigert. With this operation we gained good and very good results in 77 per cent of the 30 operated knee-joints.