Interventional treatment of para-valvular leaks after prosthetic valve replacement with plug devices -first results from a prospective registry

Background

Interventional closure of symptomatic paravalvular leaks (PVL) after surgical or interventional valve replacement by plug implantation has emerged as an alternative to surgical correction, which is associated with high morbitity and mortality rates. To date, data on procedural efficacy and clinical outcome after transcatheter closure with plugs is sparse, especially prospective data are missing.

Methods

We analysed data from a multi-center prospective registry on interventional PVL closure with plug devices.

Results

Between 06/2012 and 04/2020 55 interventions were performed with different numbers of plugs (maximal 4) in 51 patients at 9 hospitals. Interventions were performed in 15 women and 36 men at high surgical risk for repeat surgery. 48% of procedures were performed for mitral PVLs and 52% procedures were performed for aortic PVLs. Mean age of the population treated was 69±13 years and mean log. Euro-Score I was 22.5±14.2%. Patients were treated by implantation of Amplatzer Vascular Plug III (80%) and Occlutec occluders (9%). Aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (25/26) or transapical access (1/26) with 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was previous surgery (n=39), high-risk patients (n=24), heart failure (n=22), age (n=20) and hemolysis (n=12). 40 patients had NYHA class III/IV at admission. Interventional closure of PVL was completely successful in 40 procedures (73%), partially successful in 7 procedures (13%) and failed in 7 procedures (13%). NYHA class I/II after PVL closure was achieved in 75% patients. However, 8 out of 12 patients with hemolysis as indication still hemolyzed at discharge. Complications occurred in 16% of patients. In-hospital mortality rate was 4% of procedures (2/51). After hospital discharge no death occurred during 30-day follow-up.

Conclusions

In this prospective interventional PVL registry inclusion rate was lower than expected. There was an equal distribution of aortal and mitral PVLs. At least partial success could be achieved in 86% of patients, with significant functional improvement in most patients. In this high risk population hospital mortaliy was low (4%), indicating that interventional PVL treatment should be the treatment of choice, when discussed by a heart team.

Funding Acknowledgement

Type of funding sources: None.

4291Six-month outcomes from the multicenter, prospective study with the novel PASCAL transcatheter valve repair system for patients with mitral regurgitation in the CLASP study

Background

Severe mitral regurgitation may lead to an impaired prognosis if left untreated. Transcatheter treatment options have emerged as an alternative to surgery and an adjunct to medical therapy. We report the six-month results of the PASCAL transcatheter valve repair system in treating patients with mitral regurgitation enrolled in the multicenter, prospective, single arm CLASP study.

Methods

The PASCAL Transcatheter Valve Repair System is a leaflet repair therapy that uses clasps and paddles to place a woven Nitinol spacer between the native valve leaflets to fill the regurgitant orifice via a transseptal approach. Eligible patients had clinically significant MR despite optimal medical therapy and were deemed candidates for transcatheter mitral repair by the local Heart Team. Safety, performance, and clinical outcomes were prospectively assessed at baseline, discharge, 30 days, and 6 months post-procedure. All major adverse events (MAE) were adjudicated by an independent clinical events committee and echocardiographic images were assessed by a core lab. The MAE rate was the primary safety endpoint, defined as the composite of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications.

Results

Between June 2017 and September 2018, 62 patients were enrolled at 14 sites worldwide for transcatheter mitral valve reconstruction using the PASCAL system. The mean age was 76.5 years (62.9% male). All patients had MR grade ≥3+, with 59% functional, 34% degenerative, and 7% mixed etiology, and 51.6% of patients were in NYHA Class III/IV. Successful implantation of the PASCAL device was achieved in 95% of patients. At discharge, 95% of patients had MR grade ≤2+ with 81% grade ≤1+. There was one cardiovascular mortality and the MAE rate was 4.8%. At 30-day follow-up, paired analyses shows that 98% of patients had MR grade ≤2+ with 81% grade ≤1+ and 88% were in NYHA Class I/II (p<0.0001). The 6MWD improved by 38.9 m (p=0.0015) and was accompanied by average improvements in KCCQ and EQ5D scores by 14.1 points (p<0.0001) and 8.3 points (p=0.0028), respectively. The six-month data will be available for presentation.

Conclusions

In this early device experience, the PASCAL transcatheter valve repair system showed an acceptable safety profile and performed as intended in treating patients with mitral regurgitation. The PASCAL device resulted in significant MR grade reduction, which was associated with clinically and statistically significant improvements in functional status, exercise capacity, and quality of life. Continued follow-up is warranted to validate these initial promising results.

Acknowledgement/Funding

Edwards Lifesciences

P4716One-year outcomes of the tri-repair study assessing cardioband tricuspid valve reconstruction system for patients with severe tricuspid regurgitation

Background

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality rates with limited treatment options.

Objectives

We report the one-year outcomes of the Cardioband™ Tricuspid Valve Reconstruction System in the treatment of severe functional TR in 30 patients enrolled in the TRI-REPAIR study.

Methods

Between October 2016 and July 2017, 30 patients were enrolled in this single-arm, multicenter, prospective study. Patients were diagnosed with severe, symptomatic TR in the absence of untreated left-heart disease and deemed inoperable because of unacceptable risk for open-heart surgery by the local heart team. Clinical, functional, and echocardiographic data were prospectively collected before and up to one year post-procedure. An independent core lab assessed all echocardiographic data and an independent clinical event committee adjudicated the safety events.

Results

Mean patient age was 75 years, 73% were females, 23% had ischemic heart disease, and 93% had atrial fibrillation. At baseline, 83% were in NYHA Class III-IV, 63% had edema, and LVEF was 58%. Technical success was 100%. Through one year, one patient had a reintervention and exited the study. Five patients died of which one was device-related. Between baseline and one year (paired analyses), echocardiography showed average reductions of annular septolateral diameter of 16% (44mm vs. 37mm; p<0.0001), PISA EROA of 49% (0.73cm2 vs. 0.37cm2, p=0.0037), and mean vena contracta of 30% (1.2cm vs. 0.9cm, p=0.0046). Clinical assessment showed that at one year 78% of patients were in NYHA Class I-II (p=0.0003). Six minute walk distance improved by 42m (p=0.0525). Kansas City Cardiomyopathy Questionnaire score improved by 19 points (p=0.0009). Edema was absent in 70% of the patients.

Conclusions

These results show that the Cardioband tricuspid system performs as intended and appears to be safe in patients with symptomatic and severe functional TR. At one year significant reduction of TR through a sustained decrease of annular dimensions, improvements in heart failure symptoms, quality of life, and exercise capacity were observed. Further studies are warranted to validate these initial promising results.

Acknowledgement/Funding

Edwards Lifescieinces

P3858High H2FPEF score is an independent predictor of adverse outcome in patients with severe aortic stenosis and preserved ejection fraction undergoing TAVR

Background

Recently, the H2FPEF score has been developed in an evidence-based approach relying on simple clinical and echocardiographic variables. It enables the identification of patients with high probability of prevalent heart failure with preserved ejection fraction (HFpEF) which is associated with a dismal prognosis. Left ventricular diastolic dysfunction, a key mechanism in HFpEF, is also a common finding in patients with severe aortic stenosis.

Objective

To assess the prognostic impact of the H2FPEF score in patients with preserved ejection fraction and severe aortic stenosis undergoing Transcatheter Aortic Valve Replacement (TAVR).

Methods

Among 1148 patients with preserved ejection fraction who received TAVR at our institution between 2013 and 2018, data for calculation of the H2FPEF score was available in 535 patients. Score variables include BMI >30 kg/m2, arterial hypertension, atrial fibrillation, pulmonary hypertension >35 mmHg, age >60 years, and elevated LV filling pressure. Patients were dichotomized according to “low” (1–5 points; n=377) and “high” H2FPEF scores (6–9; n=158). Kaplan-Meier survival curves and Cox regression analyses were used to assess the prognostic impact of H2FPEF scores. Median follow-up time was 0.3 years.

Results

TAVR patients presenting with high H2FPEF scores had higher prevalence of moderate to severe mitral regurgitation (19.4% vs. 33.6%, p<0.001) as well as tricuspid regurgitation (15.2% vs. 35.1%, p<0.001), and presented with lower stroke volume index (42.2 ml/m2 vs. 36.0 ml/m2, p<0.001) compared to those with low H2FPEF scores. All-cause mortality one year after TAVR was significantly higher in patients in the high H2FPEF score group (10.5% vs. 21.0%, p=0.0019, Figure 1). Multivariate analysis revealed a high H2FPEF score to be independently predictive for 1-year all-cause mortality (HR 2.66, 95% CI: 1.41–5.02, p=0.025). Among the single H2FPEF score variables, atrial fibrillation (HR 3.45, 95% CI: 1.86–6.40, p<0.001) and systolic pulmonary hypertension >55 mmHg (HR=2.68, 95% CI: 0.97–7.40, p=0.057) were strong independent predictors of adverse outcome.

Figure 1. All-cause mortality of patients undergoing TAVR after one year stratified by low (1–5 points) and high (6–9) H2FPEF score

Conclusion

An elevated H2FPEF score of >6 is independently predictive for mortality in patients with preserved ejection fraction undergoing TAVR for severe aortic stenosis. Our findings provide evidence that the H2FPEF score, which was meant for diagnostic use originally, is able to serve as a prognostic tool in patients with preserved ejection fraction undergoing TAVR, highlighting the adverse impact of diastolic dysfunction in patients with preserved ejection fraction and aortic stenosis.

P1848Prevalence and outcomes in patients with Heyde syndrome after transcatheter aortic valve implantation, a single centre experience

Introduction

Heyde syndrome is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. To date only few data exist regarding the prevalence of Heyde syndrome and results after transcatheter aortic valve implantation (TAVI) for the treatment of AS.

Purpose

We sought to evaluate the prevalence of Heyde syndrome in a routine clinical cohort of patients undergoing TAVI and analyze the effectiveness of treatment of AS regarding recurrent GIB in these patients.

Methods

We conducted a retrospective single-center analysis of 2545 consecutive patients who underwent TAVI for the treatment of AS in 2008–2017. Patients with a history of GIB were identified. The diagnosis of Heyde syndrome was defined as a clinical triad of presence of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. GIB of unknown origin or related to other causes was defined as bleeding unrelated to angiodysplasia. Clinical outcomes of patients with Heyde syndrome were evaluated with emphasis on bleeding complications and recurrence of GIB.

Results

A history of GIB prior to TAVI was detected in 190 patients (7.5%) of the TAVI cohort. Among them, 143 patients had a GIB unrelated to angiodysplasia (5.6%) and 47 patients (1.8%) were diagnosed with Heyde syndrome. Median age and STS-PROM were 80.7 (75.3, 84.0) years and 4.7 (2.7, 9.0) respectively in Heyde patients. TAVI was successfully performed in all cases (66% endovascular access, 34% transapical access). The effective orifice areas increased from 0.8±0.1 cm2 to 2.1±0.5 cm2. Periprocedural major/life-threatening bleeding was found in 6 patients (12.8%), mainly access-related and none due to GIB. In 51% of Heyde-patients transfusion of 4.5±5.7 packed red blood cells was required during the index hospitalisation. During a mean follow-up of 12 months, recurrent GIB after TAVI was detected in 32% of patients with Heyde syndrome. In contrast only 18% of patients with GIB unrelated to angiodysplasia (Non-Heyde) had recurrent GIB after TAVI. In patients diagnosed with Heyde syndrome and recurrent GIB after TAVI the rate of residual mild or moderate paravalvular regurgitation was higher compared to those with an unremarkable course (73% vs. 37%, p=0.045).

Figure 1. 1-year Follow-Up

Conclusions

A relevant number of patients presenting for treatment of AS can be diagnosed with Heyde syndrome. In these patients TAVI can be successfully performed with moderate incidence of periprocedural bleeding complications but significant transfusion rates. Regardless of successful treatment of AS, recurrent GIB was detected in a significant number of Heyde patients during follow-up. The possible association with residual paravalvular regurgitation requires further investigation to improve treatment options in patients with Heyde syndrome.

Comparative study on the in vitro human skin permeation of monoterpenes and phenylpropanoids applied in rose oil and in form of neat single compounds

Essential oils are ingredients of cosmetic and health care products as well as massage oil used in aromatherapy. There is no doubt that essential oils and their components are able to permeate human skin. But information is rare dealing with percutanous absorption of essential oils in more detail. In this paper we investigated the in vitro skin permeation of monoterpenes and phenylpropanoids applied in pure rose oil and in form of neat single substances. We found that the application form had an exceeding influence on the skin permeation behaviour of the compounds. For substances applied in rose oil a clear relationship between their lipophilic character, chemical structure, and skin permeation could be confirmed. Regarding the P(app)-values the substances are ranked in the order: monoterpene hydrocarbons < monoterpene alcohols < monoterpene ketons < phenylpropanoids. In contrast, for neat single substances there were no relationships between their lipophilic characters, structures and skin permeation. Furthermore, except for alpha-pinene and isomenthone, the P(app)-values of all other substances were several times higher when applied in pure native rose oil than in their neat form. This suggests that co-operative interactions between essential oil components may promote skin permeation behaviour of essential oil and its components.

Incidence and outcome of traumatic brain injury in an urban area in Western Europe over 10 years

INTRODUCTION

Valid epidemiological data on incidence and outcome of traumatic brain injury (TBI) show great variability. A study on incidence, severity and outcome of TBI was conducted in an urban area of one million inhabitants.

MATERIALS AND METHODS

130,000 prehospital emergencies were screened for TBI.

INCLUSION CRITERIA

Glasgow Coma Scale (GCS) score <or=8 and/or Abbreviated Injury Scale for head injuries (AIS(head)) score >or=2 with confirmed TBI via appropriate diagnostics.

RESULTS

Annual incidence was 7.3/100,000. Overall mortality rate was 45.8%: 182 (28%) were prehospital deaths, 116 (17.8%) patients died in hospital. Two hundred and fourteen of 352 (60.8%) surviving patients were sufficiently rehabilitated at discharge [Glasgow Outcome Scale (GOS) score = 1], but 138 patients (39.2%) survived with persisting deficits. GOS was associated with initial GCS and AIS(head).

CONCLUSION

The incidence of TBI was lower compared to the literature. The overall mortality was high, especially prehospital and early in-hospital mortality rates.

Intracoronary enalaprilat during angioplasty for acute myocardial infarction: alleviation of postischaemic neurohumoral and inflammatory stress?

AIM

Reperfusion after myocardial ischaemia is associated with a distinct ischaemia/reperfusion injury. Since ACE-inhibition, beyond its influence on cardiac angiotensin II formation and kinin metabolism, has been shown to be cardioprotective by decreasing leucocyte adhesion and endothelin-1 (ET-1) release, we investigated the effects of intracoronary (i.c.) enalaprilat during primary angioplasty in acute myocardial infarction.

METHODS AND RESULTS

Twenty-two patients were randomized to receive i.c. enalaprilat (50 micro g) or placebo immediately after reopening of the infarct-related artery (IRA). Plasma concentrations of soluble L-selectin, P-selectin, intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), ET-1 and nitric oxide metabolite concentrations (NOx) were measured in pulmonary arterial blood. Coronary blood flow was assessed using corrected thrombolysis in myocardial infarction (TIMI) frame counts (CTFC). During reperfusion, there was a significant increase in sL-selectin, sP-selectin and ET-1 in the placebo group, which was greatly diminished by enalaprilat. Levels of sVCAM-1 and sICAM-1 were not affected in either group. CTFC in the placebo group remained higher than normal in both the IRA and nonculprit vessels, whereas myocardial blood flow improved with enalaprilat.

CONCLUSION

Enalaprilat as adjunct to primary angioplasty might be a protective approach to prevent leucocyte adhesion and the release of ET-1, thereby improving coronary blood flow.

Alpha-fetoprotein-positive carcinoma of the pancreas: a case report

We report on the case of a 19-year-old male with an alpha-fetoprotein (AFP)-producing acinar cell carcinoma of the pancreas. Tumour markers other than AFP were normal. Because of inoperability, a combined radiochemotherapy was initiated with a hyperfractionated dose of 44.8 Gy. Initially, the tumour showed a good response to irradiation and 5-fluorouracil (5-FU) application, and therapy showed sufficient local control. After combined radio-chemotherapy, AFP levels declined from about 3000 ng/ml (reference area: 0-7 ng/ml) to 18 ng/ml, but increased when widespread metastasis appeared. The patient died 18 months after the initial therapy due to general tumour progression. Originally, AFP was thought to be specific to hepatocellular carcinoma and germ cell tumours. Rarely has it been reported in other malignancies. Rare cases of acinar cell carcinomas of the pancreas were found to express AFP. Our patient is the youngest reported in the literature to date. When present, AFP expression is useful for diagnosis and as a marker for monitoring therapeutic response and recurrence of the disease.

Polyclonal anti-histamine H2 receptor antibodies detect differential expression of H2 receptor protein in primary vascular cell types

OBJECTIVE AND DESIGN

One of the factors defining cellular response might be the distribution and density of receptor subtypes on cell membranes. It was our aim to quantify and compare histamine H2 receptor expression in primary vascular cell types. We have therefore generated antibodies directed against the second extra-cellular loop of the H2 receptor.

METHODS

The specificity of polyclonal anti-H2 receptor antibodies designed for this purpose was examined by Western blot analysis and immunohistochemistry. H2 receptor expression was quantified by ELISA. Regulation of H2 receptor gene expression was analyzed by competitive RT-PCR.

RESULTS

Our results indicate that the polyclonal antibodies specifically interact with the histamine H2 receptor. Furthermore, utilizing these antibodies we were able to show significant differences in H2 receptor levels in human umbilical arterial and vein endothelial cells as well as smooth muscle cells.

CONCLUSIONS

We conclude that the antibodies generated against the extra-cellular domain of the H2 receptor are specific and can be utilized to detect and quantify H2 receptor expression. Furthermore, the significant differences in H2 receptor expression in different vascular cell types might play a critical role in defining histamine induced cellular responses during physiological or pathophysiological processes.

Nitric oxide mediates histamine induced down-regulation of H 2 receptor mRNA and internalization of the receptor protein (R1)

During agonist-dependent long-term stimulation of cells, histamine receptor subtypes are frequently down-regulated. However, the mechanisms underlying the modulation of receptor expression during long-term histamine stimulation have yet to be resolved. Based on our recently reported results showing an H1-mediated down-regulation of histamine H2 receptor mRNA in endothelial cells, our aim was to characterize the mechanism controlling rapid and long-term histamine-mediated modulation of H2 receptor expression in more detail. We were able to show that the histamine-induced down-regulation of H2 receptor mRNA and cell surface expression lasting for 24 h was accompanied by augmentation of the receptor protein level in the cytoplasmatic fraction of endothelial cells for this time period. Furthermore, changes in receptor protein levels in whole-cell lysate were negligible, indicating that the rapid and prolonged modulation of cell surface H2 receptor levels by histamine was regulated solely via internalization. The role of nitric oxide (NO) as a key mediator in histamine-stimulated cell responses was underlined by subsequent studies showing the attenuation of histamine-induced H2 receptor mRNA down-regulation and protein trafficking following NO synthase isozyme inhibition.

Lymphangiolipoma of the lower extremity: 5-year radiological follow-up after radiotherapy treatment

This report describes a lymphangiolipoma located in the extremity in a young woman. Radiotherapy effectively controlled recurrent lymphangiolipoma of the left upper leg that had been judged inoperable by limb-sparing surgical resection. In the case presented here, a dose of 50 Gy in 25 fractions over 5 weeks was employed without long-term complications after 5-year follow-up.

CT simulation in nodal positive breast cancer

BACKGROUND

A variety of solutions are used to match tangential fields and opposed lymph node fields in irradiation of nodal positive breast cancer. The choice is depending on the technical equipment which is available and the clinical situation. The CT simulation of a non-monoisocentric technique was evaluated in terms of accuracy and reproducibility.

PATIENTS, MATERIAL AND METHODS

The field match parameters were adjusted virtually at CT simulation and were compared with parameters derived mathematically. The coordinate transfer from the CT simulator to the conventional simulator was analyzed in 25 consecutive patients.

RESULTS

The angles adjusted virtually for a geometrically exact coplanar field match corresponded with the angles calculated for each set-up. The mean isocenter displacement was 5.7 mm and the total uncertainty of the coordinate transfer was 6.7 mm (1 SD). Limitations in the patient set-up became obvious because of the steep arm abduction necessary to fit the 70 cm CT gantry aperture. Required modifications of the arm position and coordinate transfer errors led to a significant shift of the marked matchline of > 1.0 cm in eight of 25 patients (32%).

CONCLUSION

The virtual CT simulation allows a precise and graphic definition of the field match parameters. However, modifications of the virtual set-up basically due to technical limitations were required in a total of 32% of cases, so that a hybrid technique was adapted at present that combines virtual adjustment of the ideal field alignment parameters with conventional simulation.

Application of automated flow injection analysis to drug liberations studies with the Franz diffusion cell

The flow-injection method with sensitive fluorimetric detection is used to monitor the liberation profiles of a topical dermatological formulation containing the model compound salicylic acid. The connection of a standard Franz diffusion cell with the automated flow-injection system enables an acquisition of multi-point liberation data in a form of series of fluorescence peaks in a short time. Examples of liberation profiles for a topical dermatological formulation containing salicylic acid are shown.

Chemokines and interleukin-18 are up-regulated in bronchoalveolar lavage fluid but not in serum of septic surgical ICU patients

Our objective was to investigate the levels of chemokines (MIP1-alpha, MCP-1, and Gro-alpha), Interleukin-18 (IL-18), and Interleukin (IL-6) in bronchoalveolar lavage (BAL) fluid and serum at the onset and ongoing states of sepsis as defined by the American College of Chest Physicians/Society of Critical Care Medicine in septic surgical ICU patients. Our summary background data was to understand the significance of compartmentalized inflammatory mediator production in an immunologically active organ (lung) in comparison with levels in the systemic circulation. The study group consisted of 20 septic patients and 10 non-septic patients on surgical ICU. At the onset of sepsis, both BAL fluid and serum samples were taken and levels of MIP-1alpha, MCP-1, GRO-alpha, IL-18, and IL-6 were measured by ELISA. Furthermore, over a subsequent 8-day period, levels of these mediators were determined in serum. In some experiments, IL-18 mRNA levels were determined in peripheral blood lymphocytes (PBL) of septic and non-septic patients. At the onset of sepsis, MIP-1alpha, MCP-1, GRO-alpha, IL-18, and IL-6 levels were significantly up-regulated in BAL fluid as compared with non-septic controls. In marked contrast, with the exception of IL-18 mRNA and IL-6 peptide, there was no increase in serum levels of inflammatory mediators determined both at the onset and during the ongoing states of sepsis. Based on the present data, monitoring levels of serum chemokines and IL-18 protein as markers of sepsis might be misleading since despite their non-detection in serum, they were highly up-regulated in the lung tissue compartment. These data might underscore the role of MIP-1alpha, MCP-1, GRO-alpha, and IL-18 in the mediation of local tissue damage. Furthermore, these findings raise the notion that mediator measurement in immunologically active organs might serve as pivotal indicators of sepsis prior to the actual fulfillment of specific clinical criteria that defines the patient as being septic.

Prostate-specific antigen (PSA) in the monitoring of prostate cancer after radical prostatectomy and external beam radiation

BACKGROUND

During the last few years, prostate-specific antigen (PSA) has been established as the most important tumor marker for prostate cancer. The aim of our study was to evaluate the response of PSA after surgery and radiotherapy of prostate cancer.

PATIENTS AND METHODS

From 1/1995 to 9/1997, 32 patients were treated by radical prostatectomy and subsequent radiotherapy. Radiation therapy was carried out using a linear accelerator to the prostate bed, a total dose of 60 Gy was given. PSA values were measured immediately before irradiation, weekly during radiation therapy and every three months thereafter in the usual follow-up pattern.

RESULTS

21 of 32 patients had no measurable PSA after surgery. In the remaining 11 patients the median PSA half-life was reached 3 months after irradiation, the nadir after 15 months. 5 patients with increasing PSA levels suffered from a relapse (15.6%).

CONCLUSIONS

We found that PSA monitoring is a useful marker for treatment outcome and that adjuvant radiotherapy after surgery improves local control as well as biochemical failure rate. If PSA is still detectable after surgery the risk for biochemical failure is significantly higher (45.5%).