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Ijgua M, Arnold M, Eckstein M, Smolka S, Bittner D, Ammon F, Kondruweit M, Moshage M, Achenbach S, Marwan M. CT analysis of left ventricular function predicts short term survival in patients following transcatheter aortic valve implantation: 1-year outcome data. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Contrast-enhanced cardiac CT routinely performed prior to transcatheter aortic valve implantation (TAVI), allows assessment of cardiac morphology and function. We assessed left ventricular function in CT as a predictor of survival following TAVI.
Methods
500 consecutive patients referred for CT assessment of aortic root anatomy prior to TAVI were screened for inclusion in this analysis. All CT data sets were acquired using a third-generation dual source system. For assessment of aortic root anatomy, acquisitions were acquired using ECG-gated retrospective spiral acquisition and multiphase reconstructions in 10% increments of the cardiac cycle were rendered (slice thickness 0.75, increment 0.4 mm). left ventricular endocardial contours were automatically traced by a dedicated software (syngo. via, Siemens Healthineers, Forchheim, Germany) throughout the cardiac cycle and manually adjusted if required. Global left ventricular function parameters (end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction) were derived by volumetric assessment.
Results
Out of 500 patients, 439 patients (mean age 80±6 years, 56% males, and Log EuroScore 23±14%) were included in this analysis (61 patients were excluded due to poor CT image quality or missing outcome data). Previous cardiac surgery had been performed in 15% of the patients, 50% had obstructive CAD with previous interventional or surgical revascularisation and 18% had a previous acute coronary syndrome. One-year survival was 83% (366/439 patients). Parameters of left ventricular function were as follows: mean LVEDV 172±56 ml, mean LVESV 78±62 ml, mean LV ejection fraction 59±18%, mean LV stroke volume index 51±22 ml/m2, mean LV cardiac output 6.6±3.3 L/min and LV cardiac index 3.5±1.7 l/min/m2. Cluster analysis of multiple LV-function surrogate parameters identified a group of patients with higher 1-year mortality, with LVEF identified as a predictor of 1-year survival with a cut-0ff of ≥37% associated with an OR 0f 0.52 (95% CI 0.27 to 0.98).
Conclusion
Assessment of left ventricular function using functional CT data sets is feasible and allows risk stratification of patients following TAVI. Among LV functional parameters, CT derived LV-ejection fraction with a cut-off ≥37% identifies patients with better short-term outcome.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- M Ijgua
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - M Arnold
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - M Eckstein
- Friedrich Alexander University, Pathology , Erlangen , Germany
| | - S Smolka
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - D Bittner
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - F Ammon
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - M Kondruweit
- Friedrich Alexander University, Cardiac Surgery , Erlangen , Germany
| | - M Moshage
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - S Achenbach
- Friedrich Alexander University, Cardiology , Erlangen , Germany
| | - M Marwan
- Friedrich Alexander University, Cardiology , Erlangen , Germany
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Jung S, Ammon F, Smolka S, Moshage M, Marwan M, Achenbach S. Membranous septum length as predictor for permanent pacemaker implantation after TAVI. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Extension of indication for TAVI towards subjects with lower surgical risk requires to reduce the likelihood for the requirement of permanent pacemaker (PPM) implantation. Data on the role of membranous septum length as potential predictor for AV block after TAVI are scarce.
Purpose
We examined the role of membranous septum length as potential predictor for AV block and the need for PPM implantation in a large cohort of consecutive subjects after TAVI.
Methods
In a cohort of 1365 patients without prior permanent pacemaker who underwent transfemoral TAVI, clinical and procedural characteristics were assessed systematically. Based on cardiac computed tomography performed prior to TAVI, membranous septum length was measured orthogonal to the anulus plane (see figure).
Results
Median age of subjects was 81 (IQR 7) years, 50% were male. Logistic euroSCORE was 12.8 (IQR 15.7), STS score 3 (2.7). 9,8% of subjects had a pre-interventional complete right bundle branch block (RBBB). 71% of patients received a balloon-expandable, 29% a self-expandable valve. In n=153 patients (11.2%), PPM implantation was necessary due to high-degree AV block. Median membranous septum length was 2.9 mm (IQR 2.5mm) in subjects who received a PPM versus 4.3 mm (IQR 3.2 mm) in subjects who did not need a PPM (p=0.061). In univariate regression analysis, pre-interventional complete RBBB (p<0.001, OR 7.8), implantation of a self-expandable prosthesis (p=0002, OR 1.7) and membranous septum length (p=0.027, OR 0.9 per 1 mm) were identified as significant predictors for PPM implantation. In multivariate regression analysis, all parameters remained significant, including membranous septum length (p=0.009, OR 0.9 per 1 mm).
Conclusion
In a large cohort of consecutive patients, we were able to confirm the significant independent predictive value of membranous septum length, in addition to pre-interventional complete RBBB or implantation of a self-expandable prosthesis, regarding the occurrence of post-procedural AV block with the need for PPM implantation. The results may contribute to improved risk stratification for potential PPM implantation after TAVI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Jung
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
| | - F Ammon
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
| | - S Smolka
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
| | - M Moshage
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
| | - M Marwan
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
| | - S Achenbach
- Friedrich Alexander University, Department of Cardiology and Angiology , Erlangen , Germany
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Ijgua M, Arnold M, Smolka S, Bittner D, Ammon F, Kondruweit M, Moshage M, Achenbach S, Marwan M. 443 Assessment Of Global Left Ventricular Function And Left Ventricular Strain In Patients Referred For Transcatheter Aortic Valve Implantation: Head To Head Comparison Between Echocardiography And Ct. J Cardiovasc Comput Tomogr 2022. [DOI: 10.1016/j.jcct.2022.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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4
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Goeller M, Duncker H, Moshage M, Dey D, Bittner D, Ammon F, Achenbach S, Marwan M. Computed tomography-derived characterisation of pericoronary,epicardial and paracardial adipose tissue and its association with myocardial ischemia as assessed by computed and invasive fractional flow. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Increased pericoronary adipose tissue (PCAT) computed tomography (CT) attenuation derived from coronary CT angiography (CTA) around the right coronary artery (RCA) reflects coronary inflammation and relates to cardiac mortality.
Purpose
We aimed to investigate the yet unclear association between CT-derived characterisation of different cardiac adipose tissue compartments and the presence of myocardial ischemia as assessed by fractional flow reserve (FFR).
Methods
133 stable individuals (64 years, 74% male) with coronary artery disease (CAD) underwent CTA including computed FFR (FFR-CT) measurement followed by invasive angiography with FFR (invasive FFR) assessment. The CT attenuation (HU) and volume (mm3) of PCAT were quantified around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) with the help of semi-automated software. The per patient PCAT CT attenuation was calculated as followed: (PCAT CT attenuation of RCA+LAD+LCX)/3. Quantification of epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT; all intrathoracic adipose tissue outside the pericardium) were performed in non-contrast cardiac CT data sets using a fully automated deep-learning based algorithm.
Results
Median FFR-CT was 0.86 [0.79, 0.91] and median invasive FFR was 0.87 [0.81, 0.93]. Patients with presence of myocardial ischemia (n=26) defined by a FFR-CT threshold of ≤0.75 showed a significant higher PCAT CT attenuation of RCA (−75.1 HU vs. −81.1 HU, p=0.011) and per patient (−74.5 HU vs. −77.7 HU, p=0.045) than individuals without myocardial ischemia (n=107). In multivariable analysis adjusted for age, BMI, gender and traditional risk factors, both RCA and per patient PCAT CT attenuation were significant predictors of myocardial ischemia as assessed by FFRCT ≤0.75. Between individuals with myocardial ischemia compared to individuals without myocardial ischemia there was no significant difference neither in the volume and CT attenuation of EAT and PAT nor in the PCAT volume of RCA, LAD, LCX and per patient PCAT volume.
Conclusions
Our observations suggest that PCAT CT attenuation instead of PCAT volume, EAT and PAT measures might be associated with the presence of myocardial ischemia as assessed by FFR.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V.
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Affiliation(s)
- M Goeller
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - H Duncker
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - M Moshage
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, United States of America
| | - D Bittner
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - F Ammon
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - S Achenbach
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - M Marwan
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
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Bargon S, Achenbach S, Gaede L, Troebs M, Marwan M, Ammon F, Ferstl P, Schacher N. Radial versus femoral approach for rotational atherectomy – technical aspects and procedural outcomes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Rotational atherectomy (RA) is a well-established therapy for the treatment of heavily calcified coronary lesions. While the radial approach has evolved into the gold-standard for standard percutaneous coronary intervention (PCI), RA is still often performed via a femoral approach. Concerns over guiding size, sheath size, the delivery of the burr as well as the need for a temporary pacemaker play a role in that decision.
Methods
This retrospective analysis includes all patients undergoing RA from 03/2013 to 06/2019 at one institution. We sought to investigate the procedural outcome and the influence of the percutaneous approach.
Results
A total of 228 patients were planned to undergo RA. Based on operator preference, RA was attempted via the radial approach (RAD) in 78 (34.2%) patients and via the femoral approach (FEM) in 150 (65.8%) patients. The procedure failed in 2.6% (RAD 1.3% vs. FEM 3.3%, p=0.359) due to crossing failure of either the RotaWire (n=5) or the burr (n=1).
The left anterior descending was the most frequently treated vessel in the radial group and significantly more often targeted in comparison to the femoral group (LAD: RAD 44.6% vs. FEM 26.5%, p=0.004). All other vessels were similarly often treated in both groups (LM: RAD 13.3% vs. FEM 17.3%, p=0.414; LCX: RAD 15.7% vs. FEM 23.5%, p=0.155; RCA: RAD 25.3% vs. FEM 31.5%, p=0.315; Bypass: RAD 1.2% vs. FEM 1.2%, p=0.984). RAD-RA was significantly more often performed with a 6F sheath in comparison to FEM-RA (RAD 47.4% vs. FEM 16.7%, p<0.001). A 7F sheath was used in 52.6% of the cases for RAD-RA (men: 85.4%, women: 14.6%, p=0.176) and is therefore the most frequently chosen sheath size within that group. A 7F or 8F sheath was used in 75.3%, respectively 8.0% of the cases in the FEM group (7F: p<0.001; 8F: p=0.010 compared to RAD). There were no significant differences regarding the burr sizes (RAD 1.43±0.17mm vs FEM 1.41±0.18mm, p=0.442).
Whereas the placement of a temporary pacemaker was equal in both groups (RAD 20.8% vs. FEM 30.8%, p=0.110), the femoral group showed a higher number of patients with any back-up pacing, permanent or temporary (RAD 24.7% vs. FEM 39.0%, p=0.031). There were no significant differences in terms of fluoroscopy time (RAD 00:24:65±00:12:48 vs. FEM 00:28:33±00:17:05, p=0.180) and the volume of contrast medium (RAD 217.2±96.3ml vs. FEM 192.9±86.0ml, p=0.118). Moreover, procedural complications (RAD 17.9% vs. FEM 18.0%, p=0.992) and access site related complications (RAD 6.4% vs. FEM 10.0%, p=0.363) occurred equivalently in both groups.
Conclusion
This analysis shows that RA via radial access is as safe and successful as via femoral access. Despite the more frequent use of 6F sheaths, burr sizes did not differ. Additionally, neither fluoroscopy time nor contrast volume indicated a higher complexity of the RAD approach.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Bargon
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - S Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - L Gaede
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - M Troebs
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - M Marwan
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - F Ammon
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - P Ferstl
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - N Schacher
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
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Goeller M, Duncker H, Bittner D, Ammon F, Moshage M, Dey D, Achenbach S, Marwan M. CT-derived characterization of pericoronary, paracardial and epicardial adipose tissue and its association with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab111.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V.
Introduction
Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA) and has been shown to be associated with cardiac mortality. Increased volume of epicardial adipose tissue (EAT) has been reported be associated with myocardial ischemia.
Purpose
We aimed to investigate a potential association between CTA-derived PCAT measures and myocardial ischemia as assessed by adenosine stress CMR perfusion imaging.
Methods
In this single-centre study 109 stable individuals (mean age of 62 ± 11 years, 77% males) with coronary artery disease underwent CTA followed by adenosine stress CMR perfusion imaging to detect myocardial ischemia. PCAT CT attenuation (HU) and PCAT volume (cm3) was measured around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Per patient PCAT CT attenuation was calculated as followed: (PCAT attenuation of RCA + LAD + LCX)/3). Non-contrast CT data sets were used for coronary calcium scoring and the quantification of EAT (located between the myocardial surface and the pericardium) and paracardial adipose tissue (PAT; intrathoracic and outside of the pericardium).
Results
Between patients with evidence of significant myocardial ischemia as assessed by adenosine stress CMR perfusion imaging (n = 35) and patients without myocardial ischemia (n = 74) there was no significant difference in the CT attenuation of RCA (-85.3 HU vs. -85.7 HU, p = 0.87), LAD (-84.8 HU vs. -85.7 HU, p = 0.66) and LCX (-82.8 HU vs. -83.2 HU, p = 0.79) as well as in the per patient PCAT CT attenuation (-84.2 HU vs. -84.9 HU, p = 0.76). Neither did patients with myocardial ischemia within the RCA territory show increased RCA PCAT CT attenuation (-87.7 HU vs. -85.3 HU, p = 0.40); nor was such a relationship found for the territory of the LAD (-80.6 HU vs. 85.8 HU, p = 0.11) or LCX (-83.1 HU vs. -83.0 HU, p = 0.99). The CT attenuation of EAT (-77.9 vs. -78.7 HU, p = 0.65) and PAT (-89.9 HU vs. -90.0 HU, p = 0.93) did not differ between patients with myocardial ischemia compared to patients without myocardial ischemia. Between patients with myocardial ischemia and patients without myocardial ischemia there was no significant difference in the volumes of EAT (118.1 cm3 vs. 110.6 cm3, p = 0.55), PAT (279.5 cm3 vs. 240.9 cm3, p = 0.20) and the per patient PCAT volume (1021.9 mm3 vs. 1015.5 mm3, p = 0.90). In logistic regression analysis the volume and CT attenuation of the different intrathoracic fat compartments PCAT, EAT and PAT were not independently associated with the presence of myocardial ischemia (n.s.).
Conclusions
In this single-centre study CTA-derived quantified CT attenuation and volume of PCAT, EAT and PAT were not associated with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging.
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Affiliation(s)
- M Goeller
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - H Duncker
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Bittner
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - F Ammon
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - M Moshage
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute , Los Angeles, United States of America
| | - S Achenbach
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - M Marwan
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
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Podzus J, Arnold M, Ammon F, Eckstein M, Bittner D, Göller M, Achenbach S, Marwan M. Ct-derived Left Ventricular Global Strain In Patients With Aortic Valve Stenosis: 1 Year Outcome Following Transcatheter Aortic Valve Implantation. J Cardiovasc Comput Tomogr 2021. [DOI: 10.1016/j.jcct.2021.06.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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8
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Mekkhala C, Mekkhala N, Eckstein M, Podzus J, Ammon F, Bittner D, Göller M, Smolka S, Achenbach S, Marwan M. Influence Of Slice Thickness And Iterative Reconstruction On Coronary Artery Calcification Quantification. J Cardiovasc Comput Tomogr 2021. [DOI: 10.1016/j.jcct.2021.06.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ferstl P, Arnold M, Goeller M, Ammon F, Smolka S, Moshage M, Uehlein S, Achenbach S, Marwan M, Bittner D. Resolution of leaflet thrombosis under anticoagulant therapy in patients after transcatheter aortic valve implantation: influence of prosthesis type and size. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Leaflet thrombosis can frequently be identified by computed tomography angiography (CTA) in patients after transcatheter aortic valve implantation (TAVI). Oral anticoagulation is assumed to lead to resolution of thrombosis. We analyzed the resolution of leaflet thrombosis after TAVI by anticoagulant therapy in serial CTA and assessed the influence of prosthesis type.
Methods
Consecutive TAVI patients who underwent CTA follow-up were screened and individuals with leaflet thrombosis on CTA (defined by the presence of hypo-attenuated leaflet thickening, HALT) in whom oral anticoagulation was initiated and who underwent follow-up CTA were included. The type of anticoagulation was according to physicians' discretion. We assessed the resolution of HALT and compared patients with and without resolution of HALT regarding prosthesis type, prosthesis diameter and type of anticoagulation.
Results
Out of 395 patients screened for participation, 36 patients (mean age 80±7, 67% men) with leaflet thrombosis underwent follow-up CTA at a medial interval of 3 months (IQR: 3; 5.75 months) after anticoagulation was initiated. 36 patients received either vitamin-K antagonists (n=28, 78%) or Factor-Xa Inhibitors (n=8, 22%). A total of 22 (61%) balloon-expandable and 14 (39%) self-expandable transcatheter aortic valves were implanted. Nominal prosthesis diameter was 23, 25, 26, 27 and 29 mm in 7 (19%), 1 (3%), 10 (28%), 7 (19%) and 11 (31%) patients, respectively. 30 patients (83%) with anticoagulation showed resolution of HALT, whereas persistent HALT was detected in 6 patients (17%), of whom 1 patient with balloon-expandable and 5 patients with self-expandable valve. No difference was seen in duration of anticoagulation between patients with and without resolution of HALT (p=0.984). In univariate analysis, prosthesis type (balloon-expandable vs. self-expandable valves) showed a significant association of self-expandable valves with lack of resolution of leaflet thrombosis (p=0.017). In multivariable logistic regression analysis, this association persisted (p=0.043) and was independent of the type of anticoagulation (p=0.660) and prosthesis diameter (p=0.942).
Conclusion
Persisting leaflet thrombosis despite anticoagulation is not infrequent and seems to be associated with prosthesis-type rather than small valve diameter or type of anticoagulation. Further research is necessary to identify structural aortic valve determinants for this finding.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- P Ferstl
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - M Arnold
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - M Goeller
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - F Ammon
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - S Smolka
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - M Moshage
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - S Uehlein
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - S Achenbach
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - M Marwan
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - D.O Bittner
- Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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10
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Goeller M, Achenbach S, Herrmann N, Bittner D, Ammon F, Kilian T, Smolka S, Uehlein S, Moshage M, Raaz-Schrauder D, Dey D, Marwan M. The association of pericoronary adipose tissue attenuation with major adverse cardiac events (MACE) and atherosclerosis-relevant inflammatory mediators. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA).
Purpose
We aimed to investigate a potential association between RCA PCAT attenuation and i) serum levels of atherosclerosis-relevant cytokines, ii) different grades of coronary calcification iii) future coronary revascularization within the same coronary artery and iV) MACE (defined by revascularization, myocardial infarction (MI) and/or cardiac death).
Methods
In 293 stable individuals (59.0±9.8 years, 69% males) with intermediate likelihood for coronary artery disease (CAD) blood was drawn and subsequently analyzed for different atherosclerosis-relevant cytokines interleukin (IL)-2, IL- 4, IL-6, IL-7, IL-8, IL-10, IL-13, Il-15, IL-17, TNF-a, IP-10, CRP, MCP-1, MIP-1a, Eotaxin and GM-CSF, followed by coronary calcium scoring (CCS) in non-contrast CT followed by CTA. PCAT CT attenuation (HU) was measured around the RCA (10 to 50 mm from RCA ostium) and the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Increased RCA PCAT attenuation was defined as PCAT attenuation above the highest quartile (>−73.5 HU). A long-term follow-up over 9.6 years was performed.
Results
PCAT attenuation was similar in different grades of coronary calcification (CAC=0,-80.3 HU; CAC 1–99, −79.2 HU; CAC 100–400, −79.5 HU; CAC >400, −81.0 HU; p>0.05). Adipocytokine MCP-1 (r=0.23, p<0.01) and pro-inflammatory mediator IL-7 (r=0.12, p=0.04) correlated positively with RCA PCAT attenuation, whereas anti-inflammatory mediators Il-4, -10 and -13 correlated inversely (each r<−0.12, each p<0.05). In patients with increased RCA PCAT attenuation the serum levels of MCP-1 were increased (2.37 vs. 2.20, p<0.01), whereas anti-inflammatory mediators IL-4 and -13 were reduced (each p<0.05). 40 patients experienced MACE during follow-up. In multivariable Cox regression analysis, when adjusted by age, gender, baseline medications, obstructive coronary stenosis and CCS, the highest quartiles of PCAT attenuation are an independent predictor of MACE (HR 7.9, p=0.035). In patients with percutaneous coronary intervention (PCI) of the RCA during follow-up, RCA PCAT attenuation was increased at baseline CTA (−73.1 vs −80.2 HU, p=0.008). In patients with PCI of the LAD or LCX during follow-up, PCAT attenuation of LAD and LCX were not increased at baseline CTA (p>0.05).
Conclusions
The information captured by PCAT attenuation is independent of coronary calcification and showed a trend towards a weak association with serum levels of atherosclerosis-relevant inflammatory biomarkers. Increased RCA PCAT attenuation is an independent predictor of MACE and could guide future prevention strategies in stable patients.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- M Goeller
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - S Achenbach
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - N Herrmann
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Bittner
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - F Ammon
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - T Kilian
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - S Smolka
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - S Uehlein
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - M Moshage
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Raaz-Schrauder
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
| | - D Dey
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, Los Angeles, United States of America
| | - M Marwan
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Faculty of Medicine, Department of Cardiology, Erlangen, Germany
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11
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Moshage M, Smolka S, Achenbach S, Ammon F, Ferstl P, Goeller M, Bittner D, Uehlein S, Bal Z, Marwan M. Influence of lesion location on the accuracy of CT derived FFR: head-to-head comparison with invasive FFR. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The accuracy of CT-derived FFR (FFRCT) has been repeatedly reported. However, the influence of lesion location on accuracy is unknown. Therefore, we evaluated the diagnostic accuracy of FFRCT to detect lesion-specific ischemia and determined the influence of lesion location (proximal vs. distal vessel segments) compared to invasively measured FFR in patients with suspected CAD.
Methods
A total of 136 vessels in which “Dual-Source”-CT coronary angiography had been performed due to suspected CAD and who were further referred for invasive coronary angiography with invasive FFR measurement within three months of the index CT examination were retrospectively identified and screened for inclusion in this analysis. Patients with either left main coronary artery stenoses, bifurcation or ostial stenoses were excluded. Invasive FFR was measured using a pressure wire (CERTUS®, St. Jude Medical, Minnesota, USA or Verrata®, Volcano, San Diego, USA). FFRCT was calculated using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany). All vessels were analyzed by an experienced observer blinded to the results of invasive FFR. Stenoses with invasively measured FFR ≤0.80 were classified as hemodynamically significant. We evaluated the diagnostic accuracy of FFRCT in proximal vs. non-proximal vessel segments. Proximal lesions included stenoses located in segment one, six, eleven and twelve. All other stenoses were categorized as distal lesions.
Results
Out of 136 coronary stenoses, 47 (35%) were located in proximal segments and 89 (65%) lesions were located in distal segments. Compared to invasive FFR, the sensitivity of FFRCT to correctly identify/exclude hemodynamically significant stenoses in proximal vessel segments was 93% (95% CI: 68–99.8%) and the specificity was 100% (95% CI: 89–100%), compared to a sensitivity of 72% (95% CI: 46.5–90%) and a specificity of 87% (95% CI: 77–94%) for FFRCT in distal lesions. The positive predictive value was 100% and the negative predictive value was 97% (95% CI: 82.8–99.5%) compared to a positive predictive value of 59% (95% CI: 42–93.9%) and a negative predictive value of 93% (95% CI: 85.4–96.3%) for proximal vs. distal vessel segment, respectively. This corresponds to an accuracy of 98% vs. 84%, respectively (p=0.02). ROC-Curve analysis showed a slightly higher – albeit non-significant – area under the curve for FFRCT to detect hemodynamic relevance in proximal lesions compared to distal lesions (AUC 0.95, p<0.001 vs. AUC: 0.86, p<0.001, respectively, p=0.2).
Conclusion
FFRCT obtained using an on-site prototype shows overall a high diagnostic accuracy for detecting lesions causing ischemia as compared to invasive FFR with a trend towards better diagnostic performance in proximal vessel segments.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- M Moshage
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - S Smolka
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - S Achenbach
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - F Ammon
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - P Ferstl
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - M Goeller
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - D.O Bittner
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - S Uehlein
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - Z Bal
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
| | - M Marwan
- Friedrich Alexander Universitaet Erlangen-Nuernberg, Erlangen, Germany
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12
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Landendinger M, Smolka S, Haug J, Troebs M, Ammon F, Marwan M, Achenbach S, Arnold M. Changes of tricuspid valve geometry after interventional implantation of an anuloplasty band. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Implantation of an anuloplasty band (Cardioband, Edwards Lifesciences) is a new treatment option for patients with functional tricuspid regurgitation (TR). The initial clinical results are promising. Nevertheless very few details about the mechanism of reducing TR beyond the basic principle of reducing the annular perimeter are known. Therefore we sought to study the changes of the tricuspid valve geometry after Cardioband implantation.
Methods
In all patients, that were treated by Cardioband implantation for tricuspid valve implantation at our institution, fluoroscopic images of the implant were optained at an angle, which would correspond to an echocardiographic “enface” view of the tricuspid valve. In these images the area enclosed by the implant, the perimeter of this area, the septal to lateral diameter, the anterior to posterior diameter and the length of the implant before and after contracting the band was measured. In all patients an echocardiographic evaluation of the tricuspid regurgitation before and after cardioband implantation was performed. These clinical finding were correlated to changes of the above mentioned dimension in the fluoroscopic images.
Results
Between October 2018 und January 2019 17 patients with severe tricuspid regurgitation were treated by Cardioband implantation. In one patient the procedure had to be aborted due to extensive movement of the tricuspid annulus. In the remaining 16 patients (mean age 78±8 years, 7 males) the procedure could be completed successfully and the required measurements were done. The mean severity grade (5 grade scale) of the TR was 3.5±0.6 before and 2±0.7 (p<0.0001) after the implantation, the corresponding mean vena contracta changed from 12±4 mm to 6±3 mm (p<0.000, 51% reduction). The area decreased after band contraction from 10.6±1.4 cm2 to 4.7±1.4 cm2 (p<0.0001; 56% reduction), the perimeter from 13.4±1.8 cm to 9.6±1.6 cm (p<0.0001; 28% reduction) the septal to lateral diameter from 2.8±0.5 cm to 1.6±0.2 cm (p<0.0001; 40% reduction), the anterior to posterior diameter from 4.8±0.9 cm to 3.8±1.0 cm (p<0.005; 19% reduction) and the measured device length from 8.6 cm±1.0 to 5.8±0.8 cm (p<0.0001; 32% reduction). The strongest correlation was seen between area reduction and reduction of the vena contracta (r=0.5), reduction of the septal to lateral dimension as well as the reduction of the device length had a weaker correlation (r=0.3 and r=0.2). The reduction of the anterior posterior diameter and perimeter reduction showed no relevant correlation with regard to TR reduction.
Conclusion
In our patient population Cardioband implantation lead to effective TR reduction. Area reduction and reduction of the septal to lateral diameter of the tricuspid valve seem to have the strongest impact. These findings may be considered when implantations techniques are being optimized or when new devices for TR treatment are developed.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
| | - S Smolka
- Friedrich Alexander University, Erlangen, Germany
| | - J Haug
- Friedrich Alexander University, Erlangen, Germany
| | - M Troebs
- Friedrich Alexander University, Erlangen, Germany
| | - F Ammon
- Friedrich Alexander University, Erlangen, Germany
| | - M Marwan
- Friedrich Alexander University, Erlangen, Germany
| | - S Achenbach
- Friedrich Alexander University, Erlangen, Germany
| | - M Arnold
- Friedrich Alexander University, Erlangen, Germany
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13
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Ammon F, Moshage M, Uehlein S, Bittner D, Göller M, Smolka S, Achenbach S, M A, M M. Influence Of Reconstructed Frame Rate On The Accuracy Of CT Derived Strain: Comparison With Echocardiography. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Ammon F, Bittner D, Hell M, Mansour H, Achenbach S, Arnold M, Marwan M. CT-derived left ventricular global strain: a head-to-head comparison with speckle tracking echocardiography. Int J Cardiovasc Imaging 2019; 35:1701-1707. [PMID: 30953252 DOI: 10.1007/s10554-019-01596-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 04/01/2019] [Indexed: 11/26/2022]
Abstract
We assessed CT-derived left ventricular strain in a cohort of patients referred for transcatheter aortic valve implantation (TAVI) and validated it against 2 dimensional speckle tracking echocardiography as the gold standard. 65 consecutive patients with symptomatic aortic valve stenosis referred for CT imaging prior to TAVI were included in this analysis. For all patients, retrospectively ECG-gated multi-phase functional CT data sets acquired with identical reconstruction parameters were available. All data sets were acquired using a third generation dual source system. In all patients, multiphase reconstructions in increments of 10% of the cardiac cycle were rendered (slice thickness 0.75, increment 0.5 mm, medium smooth reconstruction kernel) and transferred to a dedicated workstation (Ziostation2, Ziosoft Inc., Tokyo, Japan). Additional functional reconstructions for dynamic assessment and quantification of strain were processed. Multiplanar reconstructions (MPR) of the left ventricle similar to standard echocardiographic 4, 2 and apical 3 chamber views were rendered in CT. Similar to echocardiographic longitudinal strain, the perimeter of the left ventricle was manually traced within the myocardium and peak maximal shortening as a parameter representing longitudinal strain was calculated for each view and averaged to obtain a marker for global longitudinal strain (CT perimeter-derived strain). Furthermore, for quantification of 3-dimensional strain, endocardial and epicardial borders of myocardium were marked in six short axis views and peak maximum 3- dimensional strain of the myocardium was calculated in standard six basal, six mid and four apical segments. 3-dimensional strain values of the 16 standard segments as well as perimeter-derived strain values in the three standard windows were averaged to obtain global strain. Echocardiography was performed in all patients before CT data acquisition. Digital loops were acquired from three apical views (four-, two-, and three chamber views). For assessment of 2 dimensional global longitudinal strain (GLS), recordings were processed with acoustic-tracking software allowing offline semiautomated speckle-based strain analyses. The mean age of all 65 patients was 81 ± 5 years. The mean echocardiographic ejection fraction and mean echocardiographic GLS were 50 ± 12% and -13.6 ± 4.5%, respectively. The mean CT-derived peak 3-dimensional global strain and mean peak strain derived by perimeter was 43.2 ± 13.5% and -11.2 ± 3.5%, respectively. Both CTderived global 3D-strain and perimeter derived strain showed a significant correlation to GLS derived by echocardiography (r = -0.8, p < 0.0001 for 3D strain and r = 0.71, p < 0.0001 for perimeter-derived strain). Bland-Altman analysis showed a systematic underestimation (i. e. worse strain values) of CT perimeter-derived strain compared to GLS by echocardiography (mean difference -2.4% with 95% limits of agreement between 4% to -9%). ROC Curve analysis assuming a normal GLS when less than -18% showed that a CT-derived peak 3-dimensional global strain cut-off-value of 45% has a sensitivity of 91% and a specificity of 60% for detecting normal left ventricular strain (AUC 0.81, p = 0.001). For CT perimeter-derived strain, a cut-off value of -12%-assuming a normal echocardiographic GLS when less than -18%-achieved a sensitivity of 82% and a specificity of 61% (AUC of 0.82, p = 0.001) for detecting abnormal left ventricular strain. Using dedicated software, assessment of CT-derived left ventricular strain is feasible and comparable to strain derived by echocardiographic 2 dimensional speckle tracking.
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Affiliation(s)
- F Ammon
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany.
| | - D Bittner
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany
| | - M Hell
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany
| | - H Mansour
- Department of Cardiology, Ain Shams University Hospital, Cairo, Egypt
| | - S Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany
| | - M Arnold
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany
| | - M Marwan
- Department of Cardiology, Friedrich-Alexander-Universität, Ulmenweg 18, 91054, Erlangen-Nürnberg, Germany
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15
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Ammon F, Arnold M, Bittner D, Hell M, Schuhbaeck A, Roether J, Feyrer R, Achenbach S, Marwan M. P6053CT-derived left ventricular global strain in aortic stenosis patients referred for transcatheter aortic valve implantation: a head-to-head comparison with echocardiography. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- F Ammon
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - M Arnold
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - D Bittner
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - M Hell
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - A Schuhbaeck
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - J Roether
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - R Feyrer
- University Hospital Erlangen, Erlangen, Germany
| | - S Achenbach
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - M Marwan
- University Hospital Erlangen, Cardiology, Erlangen, Germany
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16
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Ammon F, Roether J, Hell M, Schuhbaeck A, Achenbach S, Schlundt C, Marwan M. 3279Influence of image reconstruction parameters on diagnostic performance of on-site CT-derived FFR: Comparison with invasively measured FFR. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.3279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- F Ammon
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - J Roether
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - M Hell
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - A Schuhbaeck
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - S Achenbach
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - C Schlundt
- University Hospital Erlangen, Cardiology, Erlangen, Germany
| | - M Marwan
- University Hospital Erlangen, Cardiology, Erlangen, Germany
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17
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Hilz M, Koehn J, Ammon F, Marcus J, Flanagan S, De Fina P, Baltadzhieva R, Schwab S, Moeller S. Valsalva maneuver shows prolonged sympathetic outflow in patients with a history of mild traumatic brain injury. J Neurol Sci 2013. [DOI: 10.1016/j.jns.2013.07.2378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Hilz M, Moeller S, Ammon F, Markus J, Flanagan S, De Fina P, Schwab S, Koehn J. Valsalva Maneuver Identifies Subtle Sympathetic Cardiac Dysfunction in Patients with Mild Traumatic Brain Injury (P05.200). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p05.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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