Current Cardiology Reviews (v.9, #4)

Which way in? The Necessity of Multiple Approaches to Transcatheter Valve Therapy by S. Bleiziffer, M. Krane, M.A. Deutsch, Y. Elhmidi, N. Piazza, B. Voss, R. Lange (268-273).
TAVI (transcatheter aortic valve implantation) is a less invasive treatment of the stenotic aortic valve whileavoiding midline sternotomy and cardiopulmonary bypass. A crimped biological valve on a self-expanding or balloonexpandablestent is inserted antegradely or retrogradely under fluoroscopy, and deployed on the beating heart. Among theworldwide TAVI programs, many different concepts have been established for the choice of the access site. Whether retrogradeor antegrade TAVI should be considered the superior approach is matter of an ongoing debate. The published literaturedemonstrates safety of all techniques if performed within a dedicated multidisciplinary team. Since there is no dataproviding evidence if one approach is superior to another, we conclude that an individualized patient-centered decisionmaking process is most beneficial, taking advantage of the complementarity of the different access options. The aim ofthis article is to give an overview of the current practice of access techniques for transcatheter based valve treatment andto outline the respective special characteristics.

Recent Advances in Transcatheter Aortic Valve Implantation: Novel Devices and Potential Shortcomings by J. Blumenstein, C. Liebetrau, A. Van Linden, H. Moellmann, T. Walther, J. Kempfert (274-280).
During the past years transcatheter aortic valve implantation (TAVI) has evolved to a standard technique forthe treatment of high risk patients suffering from severe aortic stenosis. Worldwide the number of TAVI procedures is increasingexponentially. In this context both the transapical antegrade (TA) and the transfemoral retrograde (TF) approachare predominantly used and can be considered as safe and reproducible access sites for TAVI interventions. As a newtechnology TAVI is in a constant progress regarding the development of new devices. While in the first years only theEdwards SAPIENTM and the Medtronic CoreValveTM prostheses were commercial available, recently additional devicesobtained CE-mark approval and others have entered initial clinical trials. In addition to enhance the treatment options ingeneral, the main driving factor to further develop new device iterations is to solve the drawbacks of the current TAVIsystems: paravalvular leaks, occurrence of AV-blocks and the lack of full repositionability.

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countriesand its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis.Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelatedquality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been theonly effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement(TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the riskfor SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity andhas even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVSduring recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variablespectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessmentof HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judgethis new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patientswith severe AVS with sustained effects up to two years when compared with optimal medical care and demonstratescomparable benefits relative to SAVR.;Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patientsundergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patientand finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Long-term Results After Transcatheter Aortic Valve Implantation: What do we Know Today? by Y. Elhmidi, S. Bleiziffer, N. Piazza, B. Voss, M. Krane, M-A. Deutsch, R. Lange (295-298).
Transcatheter aortic valve implantation (TAVI) is evolving rapidly as a therapeutic option in patients deemedto be at high risk for surgical aortic valve replacement. Early outcome and survival of controlled feasibility trials and single-center experience with TAVI have been previously reported. Valve performance and hemodynamics seem to improvesignificantly after TAVI. Long-term outcome up to 3 years have been demonstrated in recent studies. Admittedly, the resultsare encouraging with a survival rate at 2 and 3 years ranging from 62 to 74% and from 56 to 61% respectively. Theimprovement in hemodynamical and clinical status sustained beyond the 3 years follows up. However, paravalvular leakageafter TAVI remains an important issue in this rapidely evolving field.

Cardiac Monitoring in Patients with Syncope: Making that Elusive Diagnosis by Rajesh Subbiah, Pow-Li Chia, Lorne J. Gula, George J. Klein, Allan C. Skanes, Raymond Yee, Andrew D. Krahn (299-307).
Elucidating the cause of syncope is often a diagnostic challenge. At present, there is a myriad of ambulatorycardiac monitoring modalities available for recording cardiac rhythm during spontaneous symptoms. We provide a comprehensivereview of these devices and discuss strategies on how to reach the elusive diagnosis based on current evidencebasedrecommendations.

Infective Endocarditis Complicating Hypertrophic Obstructive Cardiomyopathy: Is Antibiotic Prophylaxis Really Unnecessary? by Ahmet Guler, Soe M. Aung, Beytullah Cakal, Can Y. Karabay, Yeliz Guler, Cevat Kirma (308-309).
Infective endocarditis is a relatively rare complication of hypertrophic cardiomyopathy. Infective endocarditisin hypertrophic cardiomyopathy is almost always seen in patients with outflow obstruction and is more common in thosewith both outflow obstruction and atrial dilatation. We present a case of culture negative mitral valve endocarditis in apreviously asymptomatic woman with hypertrophic cardiomyopathy who died in the course of the disease.

Can Lipoprotein-associated Phospholipase A2 be Used as a Predictor of Long-term Outcome in Patients with Acute Coronary Syndrome? by Sine Holst-Albrechtsen, Maria Kjaergaard, Anh-Nhi Thi Huynh, Johanne Kragh Sorensen, Susanne Hosbond, Mads Nybo (310-315).
Studies indicate that elevated plasma concentrations of lipoprotein-associated phospholipase A2 (Lp-PLA2) isassociated with increased risk of cardiovascular disease. Lp-PLA2 seems to play a crucial role in the formation of plaquesand acute inflammation, and plasma Lp-PLA2 could therefore potentially be used as a predictor of long-term outcome inACS patients. To evaluate this, data concerning Lp-PLA2 as a predictor in ACS patients was gathered through a systematicliterature review, and studies on this issue were extracted from relevant databases, incl. PubMed and Cochrane. A totalof 14 articles were retrieved, but after thorough evaluation and elimination of irrelevant articles only seven studieswere eligible for the literature review. All studies except two showed significant correlation between Lp-PLA2 and CVevents in ACS patients. Only one study found an independent value to predict CV events 30 days after ACS. Altogether,there was inconsistency in the findings regarding the potential use of Lp-PLA2 and a lack of knowledge on several issues.Lp-PLA2 seems to give valuable information on which ACS patients are prone to new events and also provides importantinformation on plaque size. However, more focused studies concerning genetic variations, time-window impact, patientswith and without CV risk factors (e.g. diabetes), and treatment effects are needed. In conclusion, Lp-PLA2 offers new insightin the pathophysiological development of ACS, but until the aforementioned issues are addressed the biomarker willmainly be of interest in a research setting, not as a predictive parameter in a clinical setting.

Out-of-Hospital Cardiac Arrest -Optimal Management by Georg M. Frohlich, Richard M Lyon, Comilla Sasson, Tom Crake, Mark Whitbread, Andreas Indermuehle, Adam Timmis, Pascal Meier (316-324).
Out-of-hospital cardiac arrest (OHCA) has attracted increasing attention over the past years because outcomeshave improved impressively lately. The changes for neurological intact outcomes has been poor but several areas haveachieved improving survival rates after adjusting their cardiac arrest care. The pre-hospital management is certainly keyand decides whether a cardiac arrest patient can be brought back into a spontaneous circulation. However, the whole chainof resuscitation including the in-hospital care have improved also. This review describes aetiologies of OHCA, risk andpotential protective factors and recent advances in the pre-hospital and in-hospital management of these patients.

Basal Septal Hypertrophy by Mihir A. Kelshiker, Jamil Mayet, Beth Unsworth, Darlington O. Okonko (325-330).
A significant clinical problem is patients presenting with exercise-limiting dyspnoea, sometimes with associatedchest pain, in the absence of detectable left ventricular (LV) systolic dysfunction, coronary artery disease, or lungdisease. Often the patients are older, female, and have isolated basal septal hypertrophy (BSH), frequently on a backgroundof mild hypertension. The topic of breathlessness in patients with clinical heart failure, but who have a normalejection fraction (HFNEF) has attracted significant controversy over the past few years. This review aims to analyse theliterature on BSH, identify the possible associations between BSH and HFNEF, and consequently explore possible pathophysiologicalmechanisms whereby clinical symptoms are experienced.

Coronary Artery Disease in Patients with Chronic Kidney Disease: A Clinical Update by Qiangjun Cai, Venkata K. Mukku, Masood Ahmad (331-339).
Chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Coronary arterydisease is the leading cause of morbidity and mortality in patients with CKD. The outcomes of CAD are poorer in patientswith CKD. In addition to traditional risk factors, several uremia-related risk factors such as inflammation, oxidative stress,endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associatedwith accelerated atherosclerosis. A number of uremia-related biomarkers are identified as predictors of cardiac outcomesin CKD patients. The symptoms of CAD may not be typical in patients with CKD. Both dobutamine stress echocardiographyand radionuclide myocardial perfusion imaging have moderate sensitivity and specificity in detecting obstructiveCAD in CKD patients. Invasive coronary angiography carries a risk of contrast nephropathy in patients with advancedCKD. It should be reserved for those patients with a high risk for CAD and those who would benefit from revascularization.Guideline-recommended therapies are, in general, underutilized in renal patients. Medical therapy should beconsidered the initial strategy for clinically stable CAD. The effects of statins in patients with advanced CKD have beenneutral despite a lipid-lowering effect. Compared to non-CKD population, percutaneous coronary intervention (PCI) is associatedwith higher procedure complications, restenosis, and future cardiac events even in the drug-eluting stent era inpatients with CKD. Compared with PCI, coronary artery bypass grafting (CABG) reduces repeat revascularizations but isassociated with significant perioperative morbidity and mortality. Screening for CAD is an important part of preoperativeevaluation for kidney transplant candidates.

Cardioembolic Stroke Diagnosis Using Blood Biomarkers by Victor Llombart, Teresa Garcia-Berrocoso, Alejandro Bustamante, Israel Fernandez-Cadenas, Joan Montaner (340-352).
Stroke is one of the main causes of death and disability in the world. Cardioembolic etiology accounts for approximatelyone fifth of all ischemic strokes whereas 25-30% remains undetermined even after an advanced diagnosticworkup. Despite there is not any biomarker currently approved to distinguish cardioembolic stroke among other etiologiesin clinical practice the use of biomarkers represents a promising valuable complement to determine stroke etiology reducingthe number of cryptogenic strokes and aiding in the prescription of the most appropriated primary and secondarytreatments in order to minimize therapeutic risks and to avoid recurrences. In this review we present an update about specificcardioembolic stroke-related biomarkers at a protein, transcriptomic and genetic level. Finally, we also focused onreported biomarkers associated with atrial fibrillation (a cardiac illness strongly related with cardioembolic stroke subtype)thus with a potential to become biomarkers to detect cardioembolic stroke in the future.