Publications by authors named "Gerrit Kaleschke"

29 Publications

  • Page 1 of 1

Maternal and neonatal complications in women with congenital heart disease: a nationwide analysis.

Eur Heart J 2021 Oct 12. Epub 2021 Oct 12.

Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.

Aims: The aim of this study was to provide population-based data on maternal and neonatal complications and outcome in the pregnancies of women with congenital heart disease (CHD).

Methods And Results: Based on administrative data from one of the largest German Health Insurance Companies (BARMER GEK, ∼9 million members representative for Germany), all pregnancies in women with CHD between 2005 and 2018 were analysed. In addition, an age-matched non-CHD control group was included for comparison and the association between adult CHD (ACHD) and maternal or neonatal outcomes investigated. Overall, 7512 pregnancies occurred in 4015 women with CHD. The matched non-CHD control group included 6502 women with 11 225 pregnancies. Caesarean deliveries were more common in CHD patients (40.5% vs. 31.5% in the control group; P < 0.001). There was no excess mortality. Although the maternal complication rate was low in absolute terms, women with CHD had a significantly higher rate of stroke, heart failure and cardiac arrhythmias during pregnancy (P < 0.001 for all). Neonatal mortality was low but also significantly higher in the ACHD group (0.83% vs. 0.22%; P = 0.001) and neonates to CHD mothers had low/extremely low birth weight or extreme immaturity (<0.001) or required resuscitation and mechanical ventilation more often compared to non-CHD offspring (P < 0.001 for both). On multivariate logistic regression maternal defect complexity, arterial hypertension, heart failure, prior fertility treatment, and anticoagulation with vitamin K antagonists emerged as significant predictors of adverse neonatal outcome (P < 0.05 for all). Recurrence of CHD was 6.1 times higher in infants to ACHD mothers compared to controls (P < 0.0001).

Conclusions: This population-based study illustrates a reassuringly low maternal mortality rate in a highly developed healthcare system. Nevertheless, maternal morbidity and neonatal morbidity/mortality were significantly increased in women with ACHD and their offspring compared to non-ACHD controls highlighting the need of specialized care and pre-pregnancy counselling.
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http://dx.doi.org/10.1093/eurheartj/ehab571DOI Listing
October 2021

Lack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease: a population-based study.

Eur Heart J 2021 Jul 16. Epub 2021 Jul 16.

Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer Campus 1, Building A1, Münster 48149, Germany.

Aims: The aim of this study was to provide population-based data on the healthcare provision for adults with congenital heart disease (ACHD) and the impact of cardiology care on morbidity and mortality in this vulnerable population.

Methods And Results: Based on administrative data from one of the largest German Health Insurance Companies, all insured ACHD patients (<70 years of age) were included. Patients were stratified into those followed exclusively by primary care physicians (PCPs) and those with additional cardiology follow-up between 2014 and 2016. Associations between level of care and outcome were assessed by multivariable/propensity score Cox analyses. Overall, 24 139 patients (median age 43 years, 54.8% female) were included. Of these, only 49.7% had cardiology follow-up during the 3-year period, with 49.2% of patients only being cared for by PCPs and 1.1% having no contact with either. After comprehensive multivariable and propensity score adjustment, ACHD patients under cardiology follow-up had a significantly lower risk of death [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.67-0.98; P = 0.03) or major events (HR 0.85, 95% CI 0.78-0.92; P < 0.001) compared to those only followed by PCPs. At 3-year follow-up, the absolute risk difference for mortality was 0.9% higher in ACHD patients with moderate/severe complexity lesions cared by PCPs compared to those under cardiology follow-up.

Conclusion: Cardiology care compared with primary care is associated with superior survival and lower rates of major complications in ACHD. It is alarming that even in a high resource setting with well-established specialist ACHD care approximately 50% of contemporary ACHD patients are still not linked to regular cardiac care. Almost all patients had at least one contact with a PCP during the study period, suggesting that opportunities to refer patients to cardiac specialists were missed at PCP level. More efforts are required to alert PCPs and patients to appropriate ACHD care.
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http://dx.doi.org/10.1093/eurheartj/ehab422DOI Listing
July 2021

Mortality and morbidity in patients with congenital heart disease hospitalised for viral pneumonia.

Heart 2020 Oct 27. Epub 2020 Oct 27.

Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University Hospital Muenster, Muenster, Germany.

Objectives: Data on the clinical outcome of patients with congenital heart disease (CHD) affected by severe viral pneumonia are limited. We analysed morbidity and mortality of viral pneumonia and evaluated the association between medical conditions, medication, vaccination and outcome specifically in patients with CHD requiring hospitalisation for viral pneumonia.

Methods: Based on data from one of Germany's largest health insurers, all cases of viral pneumonia requiring hospital admission (2005-2018) were studied. Mortality, and composites of death, transplantation, mechanical circulatory support, ventilation or extracorporeal lung support served as endpoints.

Results: Overall, 26 262 viral pneumonia cases occurred in 24 980 patients. Of these, 1180 cases occurred in patients with CHD. Compared with patients without CHD, mortality rate was elevated in patients with CHD. As a group, patients with CHD aged 20-59 years even exceeded mortality rates in patients without CHD aged >60 years. No mortality was observed in patients with CHD with simple defects <60 years of age without associated cardiovascular risk factors. On multivariable logistic regression analysis, age, CHD complexity, chromosomal anomalies, cardiac medication, use of immunosuppressants and absence of vaccination for influenza emerged as risk factors of adverse outcome.

Conclusions: We present timely data on morbidity and mortality of severe viral pneumonia requiring hospital admission in patients with CHD. Need for mechanical ventilation and risk of death in CHD increase early in life, reaching a level equivalent to non-CHD individuals >60 years of age. Our data suggest that except for patients with isolated simple defects, patients with CHD should be considered higher-risk individuals when faced with severe viral pneumonia.
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http://dx.doi.org/10.1136/heartjnl-2020-317706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223651PMC
October 2020

Stenting of modified Blalock-Taussig shunt in adult with palliated pulmonary atresia and ventricular septal defect: a case report.

Eur Heart J Case Rep 2019 Dec 13;3(4):1-4. Epub 2019 Nov 13.

Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.

Background: Adults with complex congenital heart disease palliated with systemic-to-pulmonary artery shunts have become rare and represent a particularly challenging patient group for the cardiologist. One of the complications and causes of severe clinical deterioration during long-term follow-up are progressive obstruction or total occlusion of the shunt. The risk for surgical intervention is frequently high and catheter intervention may be complicated by complex anatomy and shunt calcification.

Case Summary: We report the case of a 47-year-old man with uncorrected (palliated) pulmonary atresia and ventricular septal defect who presented with progressive cyanosis (oxygen saturation 69%) and decreasing exercise capacity. Computed tomography revealed a totally occluded modified left Blalock-Taussig (BT) shunt and a severely stenosed central shunt (Waterston-Cooley) in a patient with confluent but hypoplastic pulmonary arteries and multiple major aortic pulmonary collaterals. Due to a high operative risk, an interventional, percutaneous approach was preferred to re-do surgery. From a radial access the calcified BT shunt could be crossed with a hydrophilic guidewire. Then, a rotational thrombectomy, balloon dilatation, and bare-metal stenting at the proximal and distal anastomoses were performed. Post-interventionally, peripheral oxygen saturation increased from 69% to 82%. Clopidogrel was administered for 1 month after bare-metal stenting. At 1-year follow-up, the BT shunt was still patent on echocardiography and exercise tolerance markedly improved.

Discussion: This case highlights the benefit of percutaneous rotational thrombectomy followed by stenting of chronically occluded systemic-to-pulmonary artery shunts for further palliation in adult patients with complex congenital heart disease not suitable for surgical repair.
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http://dx.doi.org/10.1093/ehjcr/ytz201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026590PMC
December 2019

Aortic valve replacement in a patient with extra-anatomic aortic and subclavian bypasses.

Angiol Sosud Khir 2019 ;25(3):157-162

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany.

The patient was 62-year-old male who successfully underwent an anatomic repair of aortic coarctation at the age of 15 and an extra-anatomic ascending aorta- to-descending aorta bypass (graft size 20 mm) and an extra-anatomic ascending aorta to the left subclavian artery bypass (graft size 10 mm) at the age of 49. As he grew older he started presenting clinical symptoms of aortic stenosis. The echocardiogram showed a bicuspid aortic valve with severe stenosis and a mean gradient of 65 mm Hg. Despite the high surgical risk, we decided to perform an open valve replacement with installing the CPB prior to re-sternotomy with a simultaneous cannulation of the axillary and femoral arteries by reason of interrupted descending aorta. The postoperative course was uneventful.
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http://dx.doi.org/10.33529/ANGID2019309DOI Listing
November 2019

Delayed pacemaker requirement after transcatheter aortic valve implantation with a new-generation balloon expandable valve: Should we monitor longer?

Int J Cardiol 2018 Dec 26;273:56-62. Epub 2018 Jul 26.

Dept. of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany.

Objectives: To analyze the timing of appearance of conduction abnormalities (CAs) after transcatheter aortic valve implantation (TAVI), to identify predictors of delayed CAs requiring pacemaker (PM) implantation and to provide guidance regarding the duration of telemetry monitoring.

Background: How long patients remain at risk of development of CAs requiring PM implantation after TAVI and for how long they should be monitored remains unclear but is crucial when considering early discharge.

Methods: Development of CAs was studied in 701 consecutive patients treated with Edwards Sapien 3 valves and monitored with telemetry for 7 days in a single center. After excluding valve-in-valve procedures and patients with previous PM, 606 patients remained for analysis. Predictors of CAs requiring PM and the time of onset of CAs were analyzed.

Results: Of 606 patients 76 (12.5%) required a PM after TAVI. CAs requiring PM implantation occurred after 48 h in 22.4% (17 patients) and in 10.5% (8 patients) even after 5 days. Of the patients who developed high grade CAs requiring PM after 48 h, 47.1% had no CAs prior to TAVI, and 23.5% had neither pre-existing CAs nor new-developed CAs within the first 48 h after TAVI.

Conclusion: After TAVI using a new-generation balloon-expandable valve, delayed development of CAs requiring PM implantation is not uncommon, even after 5 days. More importantly, 23.5% of patients eventually requiring a delayed PM implantation had still no CAs at 48 h after TAVI in this study. These results question the safety of early discharge and support ECG monitoring for a longer time period. The most optimal way to monitor these patients is yet to be determined.
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http://dx.doi.org/10.1016/j.ijcard.2018.07.131DOI Listing
December 2018

Prevention of sudden cardiac death in patients with Tetralogy of Fallot: Risk assessment and long term outcome.

Int J Cardiol 2018 Oct 28;269:91-96. Epub 2018 Jun 28.

Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany. Electronic address:

Background: In patients with repaired Tetralogy of Fallot (ToF), implantable cardioverter defibrillators (ICD) are considered reasonable in selected adults with multiple risk factors for sudden cardiac death.

Patients And Methods: We performed a retrospective cohort study of all 174 patients with repaired ToF who are followed at the University Hospital of Muenster. We analyzed data according to the risk score previously proposed by Khairy and coworkers and patient outcome. We analyzed data separately for patients without previous sustained ventricular tachycardia (VT) (risk stratification group, n = 157) and patients with VT/secondary prevention ICD (n = 17).

Results: In the risk stratification group, a mean of 4 ± 1 risk score parameters were available. All six risk parameters were known in 10%, five in 14%. Risk score increased with availability of parameters. 15 patients with secondary prevention ICD had a mean risk score of 6.3 ± 2.2 (range 2-10). 11 patients of the risk stratification group with primary prevention ICD had a mean risk score 5.8 ± 2.4 (range 3-8). During follow-up of up to 14 years, five patients died (3%): at age 58, two at 69 and two at 76 years.

Conclusion: In the majority of patients risk score variables were incomplete, severely limiting its applicability because the true score cannot be calculated. Risk scores were not different between patients with secondary prevention ICD and patients with ICD for primary prevention based on current guidelines. Standardization of follow-up and prospective evaluation of these standards in large prospective patient cohorts is desirable to improve risk stratification in patients with ToF.
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http://dx.doi.org/10.1016/j.ijcard.2018.06.107DOI Listing
October 2018

Impact of Percutaneous Pulmonary Valve Implantation on the Timing of Reintervention for Right Ventricular Outflow Tract Dysfunction.

Rev Esp Cardiol (Engl Ed) 2018 Oct 30;71(10):838-846. Epub 2018 May 30.

Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Early surgical repair has dramatically improved the outcome of this condition. However, despite the success of contemporary approaches with early complete repair, these are far from being curative and late complications are frequent. The most common complication is right ventricle outflow tract (RVOT) dysfunction, affecting most patients in the form of pulmonary regurgitation, pulmonary stenosis, or both, and can lead to development of symptoms of exercise intolerance, arrhythmias, and sudden cardiac death. Optimal timing of restoration of RVOT functionality in asymptomatic patients with RVOT dysfunction after TOF repair is still a matter of debate. Percutaneous pulmonary valve implantation, introduced almost 2 decades ago, has become a major game-changer in the treatment of RVOT dysfunction. In this article we review the pathophysiology, the current indications, and treatment options for RVOT dysfunction in patients after TOF repair with a focus on the role of percutaneous pulmonary valve implantation in the therapeutic approach to these patients.
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http://dx.doi.org/10.1016/j.rec.2018.05.001DOI Listing
October 2018

Prevalence and impact of critical limb ischaemia on in-hospital outcome in transcatheter aortic valve implantation in Germany.

EuroIntervention 2017 Dec;13(11):1281-1287

Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany.

Aims: Peripheral artery disease (PAD) is common in patients with aortic valve stenosis (AS). This study sought to assess the prevalence of critical limb ischaemia (CLI) and its impact on in-hospital outcome in patients undergoing transcatheter aortic valve implantation (TAVI) for severe AS.

Methods And Results: All isolated TAVI procedures for AS in Germany between 2007 and 2013 were analysed regarding the stage-specific prevalence of PAD, comorbidities, in-hospital complications and mortality using diagnostic and procedural codes. Among 32,044 patients with TAVI, 3,375 (10.5%) had PAD and 654 (2.0%) CLI. TAVI patients with PAD, particularly those with CLI, had a higher incidence of periprocedural stroke, bleeding and acute kidney injury (p<0.001). The overall in-hospital mortality among TAVI without PAD, non-CLI PAD and CLI was 6.1%, 8.4% and 14.7%, respectively (p<0.001). In a multivariate logistic regression analysis, CLI was an independent predictor of in-hospital mortality (odds ratio 1.96, 95% confidence interval 1.56-2.47; p<0.001).

Conclusions: In patients undergoing TAVI, the presence of PAD is associated with an increased risk of periprocedural complications, while only CLI independently predicts increased in-hospital mortality. Whether CLI represents a marker of general poor health status resulting in poor outcome or is a modifiable risk factor whose treatment prior to TAVI can improve the outcome requires prospective studies.
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http://dx.doi.org/10.4244/EIJ-D-17-00228DOI Listing
December 2017

Association of CKD with Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation.

Clin J Am Soc Nephrol 2017 May 13;12(5):718-726. Epub 2017 Mar 13.

Department of Cardiology and Angiology I, Heart Center, Freiburg University, Freiburg, Germany; and.

Background And Objectives: Despitethe multiple depicted associations of CKD with reduced cardiovascular and overall prognoses, the association of CKD with outcome of patients undergoing transcatheter aortic valve implantation has still not been well described.

Design, Setting, Participants, & Measurements: Data from all hospitalized patients who underwent transcatheter aortic valve implantation procedures between January 1, 2010 and December 31, 2013 in Germany were evaluated regarding influence of CKD, even in the earlier stages, on morbidity, in-hospital outcomes, and costs.

Results: A total of 28,716 patients were treated with transcatheter aortic valve implantation. A total of 11,189 (39.0%) suffered from CKD. Patients with CKD were predominantly women; had higher rates of comorbidities, such as coronary artery disease, heart failure at New York Heart Association 3/4, peripheral artery disease, and diabetes; and had a 1.3-fold higher estimated logistic European System for Cardiac Operative Risk Evaluation value. In-hospital mortality was independently associated with CKD stage ≥3 (up to odds ratio, 1.71; 95% confidence interval, 1.35 to 2.17; <0.05), bleeding was independently associated with CKD stage ≥4 (up to odds ratio, 1.82; 95% confidence interval, 1.47 to 2.24; <0.001), and AKI was independently associated with CKD stages 3 (odds ratio, 1.83; 95% confidence interval, 1.62 to 2.06) and 4 (odds ratio, 2.33; 95% confidence interval, 1.92 to 2.83 both <0.001). The stroke risk, in contrast, was lower for patients with CKD stages 4 (odds ratio, 0.23; 95% confidence interval, 0.16 to 0.33) and 5 (odds ratio, 0.24; 95% confidence interval, 0.15 to 0.39; both <0.001). Lengths of hospital stay were, on average, 1.2-fold longer, whereas reimbursements were, on average, only 1.03-fold higher in patients who suffered from CKD.

Conclusions: This analysis illustrates for the first time on a nationwide basis the association of CKD with adverse outcomes in patients who underwent transcatheter aortic valve implantation. Thus, classification of CKD stages before transcatheter aortic valve implantation is important for appropriate risk stratification.
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http://dx.doi.org/10.2215/CJN.10471016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477218PMC
May 2017

Thoracic Malignancies and Pulmonary Nodules in Patients under Evaluation for Transcatheter Aortic Valve Implantation (TAVI): Incidence, Follow Up and Possible Impact on Treatment Decision.

PLoS One 2016 12;11(5):e0155398. Epub 2016 May 12.

Department of Medicine A, Hematology, Oncology and Pneumology, University Hospital Münster, Münster, Germany.

Background: Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic valve stenosis who are not eligible for operative replacement and an alternative for those with high surgical risk. Due to high age and smoking history in a high proportion of TAVI patients, suspicious findings are frequently observed in pre-procedural chest computer tomography (CCT).

Methods: CCT scans of 484 consecutive patients undergoing TAVI were evaluated for incidentally discovered solitary pulmonary nodules (SPN).

Results: In the entire study population, SPN ≥ 5 mm were found in 87 patients (18%). These patients were compared to 150 patients who were incidentally collected from the 397 patients without SPN or with SPN < 5 mm (control group). After a median follow-up of 455 days, lung cancer was diagnosed in only two patients. Neither SPN ≥ 5 mm (p = 0.579) nor SPN > 8 mm (p = 0.328) were significant predictors of overall survival.

Conclusions: Despite the high prevalence of SPNs in this single center TAVI cohort lung cancer incidence at midterm follow-up seems to be low. Thus, aggressive diagnostic approaches for incidentally discovered SPN during TAVI evaluation should not delay the treatment of aortic stenosis. Unless advanced thoracic malignancy is obvious, the well documented reduction of morbidity and mortality by TAVI outweighs potentially harmful delays regarding further diagnostics. Standard guideline-approved procedure for SPN can be safely performed after TAVI.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0155398PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4865104PMC
July 2017

Changes in the Pacemaker Rate After Transition From Edwards SAPIEN XT to SAPIEN 3 Transcatheter Aortic Valve Implantation: The Critical Role of Valve Implantation Height.

JACC Cardiovasc Interv 2016 Apr 23;9(8):805-813. Epub 2016 Mar 23.

Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany. Electronic address:

Objectives: The aim of this study was to analyze the pacemaker implantation rate (PMIR) with the new balloon-expandable Edwards SAPIEN 3 valve (S3) and the factors associated with it.

Background: The introduction of the S3 for transcatheter aortic valve replacement (TAVR) has led to a reduction in paravalvular regurgitation. There are, however, concerns that the new design may increase the PMIR.

Methods: The first 206 patients treated with the S3 were compared with 371 preceding patients treated with SAPIEN XT valves. Patients who previously underwent pacemaker or implantable cardioverter defibrillator implantation or transapical and valve-in-valve procedures were excluded from the analysis. All patients were monitored for at least 7 days. Previous and new conduction abnormalities were documented, and prosthesis implantation height was assessed for the S3.

Results: There were no significant differences in baseline characteristics between groups. The PMIR was, however, significantly higher for the S3 (19.1% vs. 12.2%; p = 0.046). The mean implantation height was significantly lower in patients requiring PMI (67%/33% vs. 72%/28% aortic/ventricular stent extension, p = 0.032). On multivariate regression analysis, implantation height was the only independent predictor of PMI (odds ratio: 0.94 [95% confidence interval: 0.90 to 0.99]; p = 0.009). It increased from 68%/32% to 75%/25% when comparing the first with the second half of S3 implantations (p < 0.0001). This change was associated with a significant decrease in PMIR from 25.9% to 12.3% (p = 0.028), no longer different from the XT valve (12.2%).

Conclusions: The PMIR after TAVR is higher with the S3 than with the XT and is independently associated with the implantation height. This increase in the PMIR may be avoided by intending an aortic stent extension >70%.
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http://dx.doi.org/10.1016/j.jcin.2015.12.023DOI Listing
April 2016

Skeletal dysplasia in a consanguineous clan from the island of Nias/Indonesia is caused by a novel mutation in B3GAT3.

Hum Genet 2015 Jul 19;134(7):691-704. Epub 2015 Apr 19.

Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.

We describe a large family with disproportionate short stature and bone dysplasia from Nias in which we observed differences in severity when comparing the phenotypes of affected individuals from two remote branches. We conducted a linkage scan in the more severely affected family branch and determined a critical interval of 4.7 cM on chromosome 11. Sequencing of the primary candidate gene TBX10 did not reveal a disease-causing variant. When performing whole exome sequencing we noticed a homozygous missense variant in B3GAT3, c.419C>T [p.(Pro140Leu)]. B3GAT3 encodes β-1,3-glucuronyltransferase-I (GlcAT-I). GlcAT-I catalyzes an initial step of proteoglycan synthesis and the mutation p. (Pro140Leu) lies within the donor substrate-binding subdomain of the catalytic domain. In contrast to the previously published mutation in B3GAT3, c.830G>A [p.(Arg277Gln)], no heart phenotype could be detected in our family. Functional studies revealed a markedly reduced GlcAT-I activity in lymphoblastoid cells from patients when compared to matched controls. Moreover, relative numbers of glycosaminoglycan (GAG) side chains were decreased in patient cells. We found that Pro140Leu-mutant GlcAT-I cannot efficiently transfer GlcA to the linker region trisaccharide. This failure results in a partial deficiency of both chondroitin sulfate and heparan sulfate chains. Since the phenotype of the Nias patients differs from the Larsen-like syndrome described for patients with mutation p.(Arg277Gln), we suggest mutation B3GAT3:p.(Pro140Leu) to cause a different type of GAG linkeropathy showing no involvement of the heart.
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http://dx.doi.org/10.1007/s00439-015-1549-2DOI Listing
July 2015

Treatment and clinical outcomes of transcatheter heart valve thrombosis.

Circ Cardiovasc Interv 2015 Apr;8(4)

From the Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.L., T.N., V.F.P., A.C.); Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy (A.L., T.N., V.F.P., A.C.); Heart Center, Segeberger Kliniken GmbH, Bad Segeberg, Germany (M.A.-W., G.R.); Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel (H.D.); Division of Cardiology, Cardiac Catheterization Laboratories, Clinica Montevergine, Mercogliano, Italy (L.C., E.S.); Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (M.B., J.G.W.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany (H.B., G.K.); Interventional Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (A.F.); Department of Cardiology, CHU de Liege, Liege, Belgium (V.L.); Department of Cardiology, Reina Sofia University Hospital, Cordoba, Spain (J.S.d.L.); Division of Cardiology, Cliniques Universitaires Saint-Luc, Universite´ Catholique de Louvain, Brussels, Belgium (J.K.); Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France (D.M.-Z., A.V.); Deaprtment of Cardiology, St. George's Hospital, London, United Kingdom (J.-C.L.); Columbia University Medical Center and Cardiovascular Research Foundation, New York (M.B.L.); and Department of Cardiothoracic Surgery, San Raffaele Scientific Institute, Milan, Italy (F.M., O.A.).

Background: Valve thrombosis has yet to be fully evaluated after transcatheter aortic valve implantation. This study aimed to report the prevalence, timing, and treatment of transcatheter heart valve (THV) thrombosis.

Methods And Results: THV thrombosis was defined as follows (1) THV dysfunction secondary to thrombosis diagnosed based on response to anticoagulation therapy, imaging modality or histopathology findings, or (2) mobile mass detected on THV suspicious of thrombus, irrespective of dysfunction and in absence of infection. Between January 2008 and September 2013, 26 (0.61%) THV thromboses were reported out of 4266 patients undergoing transcatheter aortic valve implantation in 12 centers. Of the 26 cases detected, 20 were detected in the Edwards Sapien/Sapien XT cohort and 6 in the Medtronic CoreValve cohort. In patients diagnosed with THV thrombosis, the median time to THV thrombosis post-transcatheter aortic valve implantation was 181 days (interquartile range, 45-313). The most common clinical presentation was exertional dyspnea (n=17; 65%), whereas 8 (31%) patients had no worsening symptoms. Echocardiographic findings included a markedly elevated mean aortic valve pressure gradient (40.5±14.0 mm Hg), presence of thickened leaflets or thrombotic apposition of leaflets in 20 (77%) and a thrombotic mass on the leaflets in the remaining 6 (23%) patients. In 23 (88%) patients, anticoagulation resulted in a significant decrease of the aortic valve pressure gradient within 2 months.

Conclusions: THV thrombosis is a rare phenomenon that was detected within the first 2 years after transcatheter aortic valve implantation and usually presented with dyspnea and increased gradients. Anticoagulation seems to have been effective and should be considered even in patients without visible thrombus on echocardiography.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.114.001779DOI Listing
April 2015

Aortic regurgitation severity after transcatheter aortic valve implantation is underestimated by echocardiography compared with MRI.

Heart 2014 Dec 24;100(24):1933-8. Epub 2014 Jul 24.

Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany.

Objective: Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is associated with a poor clinical outcome and its assessment therefore crucial. Quantification of AR by transthoracic echocardiography (TTE), however, remains challenging in this setting. The present study used quantitative flow measurement by cardiac MRI (CMR) with calculation of regurgitant fraction (RF) for the assessment of AR and compared the results with TTE.

Methods And Results: We included 65 patients with a mean age of 82.2±8.1 years (38 women) who underwent successful TAVI with Edwards SAPIEN valves (52 transfemoral, 13 transapical). The post-interventional degree of AR was assessed by CMR and by TTE. There was agreement between CMR and TTE with regards to the absence of severe AR. However, TTE significantly underestimated the presence of moderate AR classifying it to be mild in 38 and moderate in only 5 patients, whereas CMR found mild AR in 23 and moderate in 16 patients. Overall, there was only fair agreement between CMR and TTE regarding the grading of AR with a weighted κ of 0.33. The rate of detection of TTE for more than mild AR was only 19%.

Conclusions: Using CMR for the quantification of AR in a sizeable group of TAVI patients, we demonstrate a strong tendency of TTE to underestimate AR compared with CMR. Since higher AR severity on echocardiography has been associated with worse patient outcome, the potential incremental prognostic value of CMR should be studied prospectively in this setting.
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http://dx.doi.org/10.1136/heartjnl-2014-305665DOI Listing
December 2014

Low flow, low gradient severe aortic stenosis: diagnosis, treatment and prognosis.

EuroIntervention 2013 Sep;9 Suppl:S38-42

Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany.

Low flow, low gradient aortic stenosis is a highly challenging condition in terms of diagnosis and therapeutic management. With regard to prognosis and to management decisions, it is essential to distinguish those patients with preserved systolic left ventricular ejection fraction from patients with impaired systolic left ventricular ejection fraction, and in particular those with true severe aortic stenosis from patients who have non-significant aortic stenosis associated with reduced transvalvular flow for other reasons and who present with a functionally small valve area. In addition, measurement errors deserve particular consideration in order to avoid a misdiagnosis. Echocardiography, including low dose dobutamine stress studies, is the key diagnostic tool. Magnetic resonance imaging, invasive assessment of haemodynamics by catheterisation and quantification of valve calcification by computed tomography calcium scoring can provide additional information that helps to assess aortic stenosis severity accurately, predict outcome and guide treatment decisions. Percutaneous aortic valve implantation may provide an intervention with lower periprocedural risk in this challenging patient subset; however, further studies are required to define its exact role in this setting.
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http://dx.doi.org/10.4244/EIJV9SSA8DOI Listing
September 2013

The risk of acute kidney injury and its impact on 30-day and long-term mortality after transcatheter aortic valve implantation.

Int J Nephrol 2012 26;2012:483748. Epub 2012 Dec 26.

Division of Angiology, Department of Cardiovascular Medicine, University of Muenster, 48149 Muenster, Germany.

Background. Transcatheter aortic valve implantation (TAVI) is widely used in high risk patients (pts) with aortic stenosis. Underlying chronic kidney disease implicates a high risk of postprocedural acute kidney injury (AKI). We analyzed its occurrence, impact on hospital stay, and mortality. Methods. 150 consecutive pts underwent TAVI in our institution (mean age 81 ± 7 years; logistic EuroSCORE 24 ± 15%). AKI definition was a creatinine rise of 26.5 μmol/L or more within 48 hours postprocedural. Ten patients on chronic hemodialysis were excluded. Results. AKI occurred in 28 pts (20%). Baseline creatinine was higher in AKI pts (126.4 ± 59.2 μmol/L versus 108.7 ± 45.1 μmol/L, P = 0.09). Contrast media use was distributed evenly. Both, 30-day mortality (29% versus 7%, P < 0.0001) and long-term mortality (43% versus 18%, P < 0.0001) were higher; hospital stay was longer in AKI pts (20 ± 12 versus 15 ± 10 days, P = 0.03). Predicted renal failure calculated STS Score was similar (8.0 ± 5.0% [AKI] versus 7.1 ± 4.0% [non-AKI], P = 0.32) and estimated lower renal failure rates than observed. Conclusion. AKI remains a frequent complication with increased mortality in TAVI pts. Careful identification of risk factors and development of more suitable risk scores are essential.
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http://dx.doi.org/10.1155/2012/483748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541560PMC
February 2013

Clinical and echocardiographic outcomes after implantation of the Trifecta aortic bioprosthesis: an initial single-centre experience.

Interact Cardiovasc Thorac Surg 2013 Feb 15;16(2):112-5. Epub 2012 Nov 15.

Department of Cardiac Surgery, Universitätsklinikum Münster, Münster, Germany.

Objectives: The Trifecta valve (St. Jude Medical) was introduced into clinical practice as a tri-leaflet stented pericardial valve designed for supra-annular placement in the aortic position. The present study aims to evaluate the preliminary results with this new bioprosthesis.

Methods: Seventy patients underwent aortic valve replacement (AVR) with the Trifecta valve between August 2010 and December 2011. Thirty-three patients were male and 37 were female (52.9%). Mean age was 74.65 ± 7.63 (range 47-90 years). Prevalent cause of AVR was aortic stenosis in 64 (91.43%) patients. The mean preoperative pressure gradient was 50 ± 17 (range 20-84 mmHg), and the mean aortic valve area was 0.77 ± 0.33. Five (7.14%) patients were operated on due to aortic valve endocarditis. One patient was operated on due to isolated, severe aortic insufficiency. All patients were in New York Heart Association functional class III or IV. Twenty-eight (40%) patients underwent concomitant procedures.

Results: Concomitant procedures were coronary artery bypass grafting (n = 25), mitral valve replacement (n = 1), ablation of atrial fibrillation (n = 1) and septal myomectomy (n = 1). There were no intraoperative deaths. The 30-day in-hospital mortality was 2.85% (2 of 70). One late death occurred during the in-hospital stay due to a multiorgan failure on postoperative day 60. There were 2 (2.85%) perioperative strokes. Mean pressure gradient decreased significantly from a preoperative value of 50 ± 17 mmHg to an intraoperative gradient of 9 ± 4 mmHg (Table 3). The mean gradients were 14, 11, 11, 8 and 6 mmHg for the 19, 21, 23, 25 and 27 mm valve size, respectively. No prosthesis dislocation, endocarditis, valve thrombosis or relevant aortic regurgitation was observed at discharge.

Conclusions: The initial experience with the Trifecta valve bioprosthesis shows excellent outcomes with favourable early haemodynamics. Further studies with longer follow-up are needed to confirm those preliminary results.
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http://dx.doi.org/10.1093/icvts/ivs460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548539PMC
February 2013

Longitudinal left ventricular 2D strain is superior to ejection fraction in predicting myocardial recovery and symptomatic improvement after aortic valve implantation.

Int J Cardiol 2013 Sep 4;167(5):2239-43. Epub 2012 Jul 4.

Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.

Background: Predicting improvement of myocardial function after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) remains a challenge. As ejection fraction (EF) may be of limited value in detecting early myocardial dysfunction and predicting outcome, we assessed the potential of echocardiographic longitudinal function in this setting.

Materials And Methods: Left ventricular (LV) function was assessed using EF, mitral annular plane systolic excursion (MAPSE), peak longitudinal 2D strain (LS) and strain rate (SR) in101consecutive patients with severe symptomatic AS (age 81 ± 11 years) undergoing TAVI. Echocardiography and assessment of clinical status including NYHA functional class were performed prior and after intervention (median 70 days).

Results: Pre-interventional EF was 57 ± 17% and 32 patients (32%) had an EF<50% while 58 patients (57%) were found to have an impaired LS. After TAVI there was no significant change in EF. In contrast, LS, SR and MAPSE improved significantly (-14.0 ± 4.4 vs. -15.5 ± 4.0%; p=0.007, 0.68 ± 0.24 vs. 0.78 ± 0.23/s, p=0.002; and 9.1 ± 3.2 vs. 10.2 ± 3.3mm, p=0.006, respectively). Receiver Operating Curve characteristic analysis identified a pre-TAVI LS>-13.3% as the optimal cut-off value for predicting lack of LS recovery post TAVI. There was a marked improvement in NYHA FC after intervention (p=0.0002). Among the studied echocardiographic parameters LS change correlated closest with NYHA class improvement (r=0.42, p=0.0008).

Conclusion: Overall, LS appears to be more sensitive for detecting early myocardial damage in patients with AS compared to conventional echocardiographic parameters. More importantly, pre-interventional LS may identify irreversible myocardial dysfunction and LS improvement correlates with symptomatic improvement after intervention.
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http://dx.doi.org/10.1016/j.ijcard.2012.06.012DOI Listing
September 2013

Impact of transcatheter aortic valve implantation or surgical aortic valve replacement on right ventricular function.

Heart 2012 Sep 11;98(17):1299-304. Epub 2012 Jun 11.

Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital Muenster, Muenster, Germany.

Objective: Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement (sAVR) in selected high risk patients. While improvement in left ventricular function after TAVI has been demonstrated, little is known about the impact on right ventricular (RV) function. Since postoperative RV dysfunction is linked to adverse outcomes, the authors sought to investigate the effect of TAVI and aortic valve replacement (AVR) on RV function using speckle tracking echocardiography.

Design: Cross-sectional study in tertiary healthcare setting.

Setting: 101 patients with severe symptomatic aortic stenosis (age 81 ± 11 yrs) who underwent TAVI and 22 patients who underwent sAVR were included. RV function was assessed using 2D longitudinal strain (RV-LS), fractional area change and tricuspid annular plain systolic excursion before and after sAVR and TAVI (median 89 days).

Results: Although the TAVI group had worse baseline characteristics, RV function remained unchanged in this group whereas significant deterioration of RV function was observed in patients undergoing conventional AVR: RV-LS (-25.2 ± 6.1 vs -20.0 ± 7.0%; p=0.009), RV-fractional area change (47.0 ± 7.0 vs 39.8 ± 10.7%, p=0.019) and tricuspid annular plain systolic excursion (24 ± 5 vs 16 ± 4 mm, p=0.0001).

Conclusion: While TAVI did not affect RV function it deteriorated significantly in patients undergoing sAVR. The authors speculate that this may be related to the detrimental effects of pericardiotomy and, to a lesser degree, cardiopulmonary bypass. While further studies are required to assess the clinical significance of this finding, these data suggest that patients with pre-existing RV dysfunction may benefit from TAVI and that RV function should be incorporated into future risk scores.
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http://dx.doi.org/10.1136/heartjnl-2011-301203DOI Listing
September 2012

Thrombembolic occlusion of crural arteries following transcatheter aortic valve implantation--successful endovascular recanalization using a thrombus aspiration device.

Vasa 2012 May;41(3):225-8

Department of Cardiology and Angiology, University of Muenster, Germany.

Transcatheter aortic valve implantation (TAVI) has become an increasingly used alternative to conventional surgical valve replacement in patients with severe aortic valve stenosis (AS) and high operative risk. We here describe a case of a TAVI performed in local anesthesia causing intraprocedural thromboembolic occlusion of non-stenotic crural arteries and its immediate successful therapeutic management by means of endovascular recanalization using a thrombus aspiration device.
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http://dx.doi.org/10.1024/0301-1526/a000190DOI Listing
May 2012

Pregnancy in congenital and valvular heart disease.

Heart 2011 Nov;97(21):1803-9

Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University of Muenster, Muenster, Germany.

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http://dx.doi.org/10.1136/heartjnl-2011-300369DOI Listing
November 2011

Asymptomatic aortic stenosis: when to operate?

Curr Cardiol Rep 2011 Jun;13(3):220-5

Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University Hospital Muenster, Albert-Schweitzer-Str. 33, 48149 Muenster, Germany.

Although there is general agreement that symptomatic aortic stenosis (AS) requires urgent surgery, it remains controversial when to operate on asymptomatic but nevertheless severe AS. Current practice guidelines recommend valve replacement in patients in asymptomatic when the systolic left ventricular function is found to be reduced without other explanation. Otherwise, surgery should be or at least may be considered (recommendation classes IIa or IIb) in asymptomatic patients with severe AS and an abnormal exercise test, a high likelihood of rapid progression, or very severe AS in the presence of low surgical risk. This article reviews recent publications evaluating early elective surgery versus watchful waiting as recommended by current guidelines. The second focus of this review is on new insights on predictors of outcome in asymptomatic AS that may improve timing of surgery and therefore deserve to be considered in future recommendations for the treatment of this difficult patient group.
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http://dx.doi.org/10.1007/s11886-011-0178-1DOI Listing
June 2011

Right ventricular-left ventricular interaction in adults with Tetralogy of Fallot: a combined cardiac magnetic resonance and echocardiographic speckle tracking study.

Int J Cardiol 2012 Feb 9;154(3):259-64. Epub 2010 Oct 9.

Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University Hospital of Muenster, Muenster, Germany.

Objectives: To assess ventricular dysfunction and ventricular interaction after repair of Tetralogy of Fallot (ToF) employing echocardiography speckle-tracking and cardiac magnetic resonance imaging (CMR).

Background: Severe pulmonary regurgitation and right ventricular (RV) dysfunction are common after repair of ToF and may also affect the shape and function of the left ventricle (LV). Recent studies suggest that LV dysfunction may be of particular prognostic value.

Methods And Results: Twenty-one consecutive adults with repaired ToF (15 male, mean age 38 ± 11 years, 7 with severe PR) underwent a comprehensive echocardiographic exam including speckle-tracking analysis, CMR and cardiopulmonary exercise testing. Twenty-one subjects without relevant heart disease served as controls. Echocardiographically measured RV diameters correlated with RV volumes obtained from CMR (r=0.63; p=0.006). In addition, a close correlation was found between RV and LV function on CMR (r=0.74, p=0.002), speckle-tracking LV and RV peak longitudinal 2D strain (r=0.66, p=0.003) and mitral and tricuspid annular plain systolic excursion (r=0.71, p=0.0003). While LV ejection fraction was normal in the majority of patients and not different from controls, LV longitudinal strain was significantly reduced in ToF patients (-16.5 ± 3.3 vs. -20.5 ± 2.7%, p=0.0001).

Conclusion: Left and right ventricular function both by CMR and speckle-tracking is interrelated in adults with repaired ToF. Despite normal LV ejection fraction, 2D longitudinal strain is significantly reduced in ToF patients, suggesting subclinical LV myocardial damage. Considering the potential prognostic value of LV dysfunction in ToF, this measurement may gain importance and should be included in future outcome studies.
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http://dx.doi.org/10.1016/j.ijcard.2010.09.031DOI Listing
February 2012

Imaging decision-making for transfemoral or transapical approach of transcatheter aortic valve implantation.

EuroIntervention 2010 May;6 Suppl G:G20-7

Adult Congenital and Valvular Heart Disease Center Muenster, Department of Cardiology and Angiology, University of Muenster, Muenster, Germany.

Transcatheter aortic valve implantation has been shown to be a feasible alternative to surgical aortic valve replacement in selected high-risk patients. Although, being less invasive, catheter techniques remain associated with the potential of serious complications. Procedural success and avoidance of such complications critically depends on careful patient selection and comprehensive preprocedural evaluation of vascular access, cardiac and aortic root anatomy. This article reviews the role of currently available imaging modalities for appropriate patient selection and decision between transfemoral and transapical approach.
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http://dx.doi.org/10.4244/DOI Listing
May 2010

Prospective, multicentre validation of a simple, patient-operated electrocardiographic system for the detection of arrhythmias and electrocardiographic changes.

Europace 2009 Oct;11(10):1362-8

Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie, Universitätsklinikum Münster, D-48129 Münster, Germany.

Aims: Electrocardiographic changes, e.g. arrhythmias causing syncope or palpitations, are often transient and therefore difficult to diagnose. Systematic and symptom-activated ECG recordings can increase diagnostic yield in such patients. We evaluated the diagnostic accuracy of a simple, leadless, patient-operated ECG device compared with a standard 12-lead ECG.

Methods And Results: We recorded a standard 12-lead surface ECG and a patient-activated ECG in direct succession in 508 consecutive patients enrolled in four centres. All ECGs were analysed by a single, blinded observer. ECGs were analysable in 505 (99.4%) patients (66% male, age 61 +/- 15 years, and body mass index 27 +/- 4). Analysis of the patient-activated ECG adequately detected a normal ECG (sensitivity 91% and specificity 95%), atrial fibrillation (AF) (sensitivity 99% and specificity 96%), and even T-wave abnormalities (sensitivity 90% and specificity 75%). Diagnostic accuracy for atrioventricular nodal block was moderate (sensitivity 79% and specificity 99%). Continuous parameters correlated well: (r(2) = 0.89 for heart rate, 0.83 for PR interval, 0.78 for QRS duration, and 0.89 for QTc).

Conclusion: Recordings made by this patient-operated ECG device allow to detect arrhythmias and other ECG changes with high accuracy compared with a standard ECG. It may help to improve accurate diagnosis of transient ECG changes such as paroxysmal AF in palpitations or other unexplained cardiac symptoms.
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http://dx.doi.org/10.1093/europace/eup262DOI Listing
October 2009
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