Liver disease epidemiology and burden in patients with alterations in plasma protein metabolism: German retrospective insurance claims analysis

BACKGROUND

Alpha-1 antitrypsin deficiency is a rare genetic disease and a leading cause of inherited alterations in plasma protein metabolism (APPM).

AIM

To understand the prevalence, burden and progression of liver disease in patients with APPM including alpha-1 antitrypsin deficiency.

METHODS

We conducted a retrospective analysis of anonymized patient-level claims data from a German health insurance provider (AOK PLUS). The APPM cohort comprised patients with APPM (identified using the German Modification of the International Classification of Diseases-10th Revision [ICD-10-GM] code E88.0 between 01/01/2010-30/09/2020) and incident liver disease (ICD-10-GM codes K74, K70.2-3 and K71.7 between 01/01/2012-30/09/2020). The control cohort comprised patients without APPM but with incident liver disease. Outcomes were incidence/prevalence of liver disease in patients with APPM, demographics/baseline characteristics, diagnostic procedures, progression-free survival (PFS), disease progression and mortality.

RESULTS

Overall, 2680 and 26299 patients were included in the APPM (fibrosis, 96; cirrhosis, 2584) and control (fibrosis, 1444; cirrhosis, 24855) cohorts, respectively. Per 100000 individuals, annual incidence and prevalence of APPM and liver disease was 10-15 and 36-51, respectively. In the APPM cohort, median survival was 4.7 years [95% confidence interval (CI): 3.5-7.0] and 2.5 years (95%CI: 2.3-2.8) in patients with fibrosis and cirrhosis, respectively. A higher proportion of patients in the APPM cohort experienced disease progression (92.0%) compared with the control cohort (67.2%). Median PFS was shorter in the APPM cohort (0.9 years, 95%CI: 0.7-1.1) compared with the control cohort (3.7 years, 95%CI: 3.6-3.8; P < 0.001). Patients with cirrhosis in the control cohort had longer event-free survival for ascites, hepatic encephalopathy, hepatic failure and esophageal/gastric varices than patients with cirrhosis in the APPM cohort (P < 0.001). Patients with fibrosis in the control cohort had longer event-free survival for ascites, cirrhosis, hepatic failure and esophageal/gastric varices than patients with fibrosis in the APPM cohort (P < 0.001). In the APPM cohort, the most common diagnostic procedures within 12 mo after the first diagnosis of liver disease were imaging procedures (66.3%) and laboratory tests (51.0%).

CONCLUSION

Among patients with liver disease, those with APPM experience substantial burden and earlier liver disease progression than patients without APPM.

[Morphological and functional diagnostics of coronary artery disease by computed tomography]

Computed tomography coronary angiography (cCTA) is a safe option for the noninvasive exclusion of significant coronary stenoses in patients with a low or moderate pretest probability for coronary artery disease (CAD). Furthermore, it also allows functional and morphological assessment of coronary stenoses. The European Society of Cardiology (ESC) guidelines on the diagnosis and management of chronic coronary syndrome published in 2019 have strengthened the importance of cCTA in this context and for this reason it has experienced a considerable upgrade. The determination of the Agatston score is a clinically established method for quantifying coronary calcification and influences the initiation of drug treatment. With technologies, such as the introduction of electrocardiography (ECG)-controlled dose modulation and iterative image reconstruction, cCTA can be performed with high image quality and low radiation exposure. Anatomic imaging of coronary stenoses alone is currently being augmented by innovative techniques, such as myocardial CT perfusion imaging or CT-fractional flow reserve (FFR) but the clinical value of these methods merits further investigation. The cCTA could therefore develop into a gatekeeper with respect to the indications for invasive coronary diagnostics and interventions.

Ungewöhnlicher Suizid durch Verbluten aus einer Hautvene

Ein 90-jähriger Mann verstarb durch protrahiertes Verbluten aus einer, mittels Rasierklinge minimal eröffneten, oberflächlichen Beinvene über der Patella und nachfolgender Manipulation. Dabei handelte es sich wahrscheinlich um einen Ast der V. saphena accessoria anterior. Es lag zunächst eine Fehleinschätzung durch den leichenschauhaltenden Arzt vor, der von einer gastrointestinalen Blutung als Todesursache ausging. Diese Einschätzung teilten die Kriminalbeamten aufgrund der Auffindesituation nicht. Begünstigend war eine vorbestehende Varikosis. Die Einnahme von Antikoagulanzien oder eine vorbestehende oder erworbene Gerinnungsstörung konnte nicht nachgewiesen bzw. eruiert werden. Bei Vorlage eines Abschiedsbriefes und Ausschluss fremder Gewalteinwirkungen oder einer Vergiftung kann plausibel von einem ungewöhnlichen suizidalen Ereignis ausgegangen werden. Es wird über die Auffindung sowie die Ergebnisse der Sektion und umfangreicher Zusatzuntersuchungen berichtet.

Epidemiology, healthcare utilization, and related costs among patients with IPF: results from a German claims database analysis

Background

Idiopathic pulmonary fibrosis (IPF) is a progressive form of fibrosing interstitial pneumonia with poor survival. This study provides insight into the epidemiology, cost, and disease course of IPF in Germany.

Methods

A cohort of incident patients with IPF (n = 1737) was identified from German claims data (2014–2019). Incidence and prevalence rates were calculated and adjusted for age differences compared with the overall German population. All-cause and IPF-related healthcare resource utilization as well as associated costs were evaluated per observed person-year (PY) following the initial IPF diagnosis. Finally, Kaplan–Meier analyses were performed to assess time from initial diagnosis to disease deterioration (using three proxy measures: non-elective hospitalization, IPF-related hospitalization, long-term oxygen therapy [LTOT]); antifibrotic therapy initiation; and all-cause death.

Results

The cumulative incidence of IPF was estimated at 10.7 per 100,000 individuals in 2016, 10.9 in 2017, 10.5 in 2018, and 9.6 in 2019. The point prevalence rates per 100,000 individuals for the respective years were 21.7, 23.5, 24.1, and 24.1. On average, ≥ 14 physician visits and nearly two hospitalizations per PY were observed after the initial IPF diagnosis. Of total all-cause direct costs (€15,721/PY), 55.7% (€8754/PY) were due to hospitalizations and 29.1% (€4572/PY) were due to medication. Medication accounted for 49.4% (€1470/PY) and hospitalizations for 34.8% (€1034/PY) of total IPF-related direct costs (€2973/PY). Within 2 years of the initial IPF diagnosis (23.6 months), 25% of patients died. Within 5 years of diagnosis, 53.1% of patients had initiated LTOT; only 11.6% were treated with antifibrotic agents. The median time from the initial diagnosis to the first non-elective hospitalization was 5.5 months.

Conclusion

The incidence and prevalence of IPF in Germany are at the higher end of the range reported in the literature. The main driver for all-cause cost was hospitalization. IPF-related costs were mainly driven by medication, with antifibrotic agents accounting for around one-third of the total medication costs even if not frequently prescribed. Most patients with IPF do not receive pharmacological treatment, highlighting the existing unmet medical need for effective and well-tolerated therapies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-01976-0.

[Factors influencing the choice of androgen deprivation therapy for patients with hormone-sensitive prostate cancer : Results of the ProComD study]

BACKGROUND

Androgen deprivation therapy (ADT) with a GnRH agonist or the GnRH antagonist degarelix is a central component in the treatment of prostate cancer (PCa). Little is currently known regarding the decision criteria. Knowledge of these could improve the success of treatment in the future.

OBJECTIVES

To identify factors influencing the treatment decision in patients with hormone-sensitive prostate cancer receiving ADT and to determine the incidence of concomitant disease in both treatment groups.

METHODS

The two-arm, prospective, non-interventional study "ProComD" was conducted from September 2014 to June 2019 at 80 study centers in Germany. After the therapy decision was made, patients with hormone-sensitive prostate cancer needing ADT were included in the study. Data were collected during routine visits.

RESULTS

Data from 413 patients were evaluated (degarelix N = 268; GnRH agonists N = 145). Key factors influencing the therapy decision for both treatment options included comorbidities (42% of all patients), compliance (64%), and age (81%). The source of information consulted most frequently regarding existing comorbidities was the patient's medical history conducted by the treating urologist themselves (65% in both groups). For patients with pre-existing cardiovascular diseases, the doctor's letter (45.8% degarelix vs. 38.9% GnRH agonists) or the medical history questionnaire (38.9% degarelix vs. 20% GnRH agonists) was additionally taken into account.

CONCLUSION

Comorbidities along with age and compliance are among the key factors influencing the treatment decisions made by urologists.

Recurrence of atrial fibrillation after pulmonary vein isolation in dependence of arterial stiffness

Background

Arterial stiffness (AS) has emerged as a strong predictor of cardiovascular (CV) diseases. Although increased AS has been described as a predictor of atrial fibrillation (AF), its role as a risk marker for AF recurrence has not yet been elucidated.

Methods

Patients with AF who underwent pulmonary vein isolation (PVI) were included in this study. Presence of AS was evaluated by measuring aortic distensibility (AD) of the descending aorta by transoesophageal echocardiography.

Results

In total, 151 patients (mean ± standard deviation (SD) age 71.9 ± 9.8 years) were enrolled and followed for a median duration of 21 months (interquartile range 15.0–31.0). During follow-up, AF recurred in 94 (62.3%) patients. AF recurrence was seen more frequently in patients with permanent AF (27% vs 46%, p = 0.03) and in those who had undergone prior PVI (9% vs 23%, p = 0.02). AD was significantly reduced in patients with AF recurrence (mean ± SD 2.6 ± 2.3 vs 1.5 ± 0.7 × 10⁻³ mm Hg⁻¹, p < 0.0001), as well as left atrial volume index (LAVI) (mean ± SD 29 ± 12 vs 44 ± 15 ml/m², p < 0.0001). Multivariable analysis revealed LAVI (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2–3.4) and AS (OR 3.6, 95% CI 2.8–4.1) as independent risk factors of AF recurrence.

Conclusion

Increased AS and left atrial size were independent predictors of AF recurrence after PVI. AD as surrogate marker of AS seemed to reflect the overall CV risk. In addition, AD was significantly correlated with left atrial size, which suggests that increased AS leads to atrial remodelling and thus to AF recurrence.

Trial registration

German registry for clinical studies (DRKS), DRKS00019007.

Supplementary Information

The online version of this article (10.1007/s12471-021-01644-w) contains supplementary material, which is available to authorized users.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]

OBJECTIVES

To determine the optimal management of singleton breech presentation.

MATERIALS AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C).

CONCLUSION

In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

P6179Correlation of computed tomography-based fractional flow reserve with instantaneous wave free ratio to detect hemodynamically significant coronary stenoses

Background

Based on coronary computed tomography angiography (cCTA), stenoses can be detected but provides anatomical assessment solely. Fractional flow reserve based on coronary CT angiography (ML-cFFR) is gaining in importance for non-invasive hemodynamic assessment of obstructive coronary artery disease (CAD), as several large trials demonstrated significantly improvements in diagnostic accuracy to cCTA. Comparably instantaneous wave free ratio (iFR) is a novel resting index for the invasive determination of haemodynamic relevant stenoses, finds consideration in the ESC guideline on myocardial revascularization and is now of equal standing with FFR as a class IA recommendation.

Purpose

The aim of our study was to evaluate the on-site ML-cFFR in terms of diagnostic accuracy and clinical practicability in comparison to the iFR as the current invasive gold standard to detect hemodynamically significant coronary artery stenoses.

Methods

In our prospective, multi-center study, patients with CAD who had a clinically indicated cCTA and subsequent invasive coronary angiography with iFR-measurement were included. To analyse the acquired cCTA dataset we used a third-generation dual-source CT with on-site prototype ML-cFFR software that is based on a machine-learning algorithm, to determine the hemodynamic relevance of coronary stenoses.

Results

Between July 2017 and December 2018, in 40 of 42 cases (95%), the on-site ML-cFFR calculation was successful. Finally we enrolled 40 patients (72.5% males, mean age 66.7±11.9 years) with ML-cFFR calculation based on cCTA and iFR-measurement during ICA. The mean calculation time of the ML-cFFR values was 10.6±1.9minutes. 57 vessel specific lesions were analysed, of which 15 (26%) were determined as hemodynamically relevant stenoses by iFR (iFR≤0.89) whereas ML-cFFR classified only 14 (24.5%) as hemodynamic significant coronary stenoses (ML-cFFR≤0.80). We observed that cCTA overestimated the severity of stenoses in 27 of 40 cases, which might lead to unnecessary coronary angiographies. However, ML-cFFR detected no obstructive CAD in 26 of 40 patients (65%) and this would have resulted in a reduction of initially performed pure diagnostic coronary angiography. Estimated values sensitivity, specificity, PPV and NPV were 86.7%, 97.4%, 92.9% and 95.0%. The diagnostic accuracy of ML-cFFR in terms of iFR on a per-patient and per-lesion level was 95.0% and 96.5%. The area under the curve (AUC) on a per-lesion and per-patient basis by ML-cFFR to detect lesion specific ischemia was 0.97 and 0.96. The analysis of the correlation (Pearson's product-moment) on a per-lesion level was r=0.82 (p<0.0001) between the ML-cFFR algorithm and iFR.

Conclusion(s)

On-site ML-cFFR correlates excellently with the novel gold standard iFR to non-invasively detect hemodynamic significant coronary stenoses in routine clinical practice.

Acknowledgement/Funding

Doctor S. Baumann receives research support from Siemens and Philips Volcano. All other authors declare that they have no financial disclosure.

P2809Comparison between treatment of “established” versus complex “off-label” coronary lesions with Absorb bioresorbable scaffold implantation: results from the GABI-R registry

Objectives

The purpose of this study was to compare the clinical outcomes of patients treated with bioresorbable scaffold (BRS) for off-label versus approved indications.

Background

The BRS promised some advantages in terms of complete biodegradation, however, the implication of BRS for off-label indications is not well described.

Methods

The short- and long-term outcome after implantation of a bioresorbable scaffold system (ABSORB, Abbott Vascular, USA) was evaluated in the prospective, non-interventional, multicenter real-world German-Austrian ABSORB RegIstRy (GABI-R).

Results

A total of 3,188 patients were enrolled. Patients were divided into two groups: on-label BRS use (33.0%) and off-label use (66.9%) if at least one off-label use criteria was met. The incidence of scaffold thrombosis in confirmed cases was significantly higher in off-label group (1.36% vs. 0.57%, p=0.04; OR 2.41 (95% CI: 1.00–5.82) with also a trend towards higher myocardial infarction rate (2.39% vs. 1.42%, p=0.077; OR 1.70 (95% CI: 0.95–3.03) and cardiovascular death (1.27% vs. 1.14%, p=0.76, OR 1.11 (95% CI: 0.56–2.21) at 6 months follow up.

Clinical outcome at 6 months Total Off-label On-label p-value* OR (95%-CI) Patients with 6m FU record 99.0% 99.0% 99.1% 0.82 0.92 (0.43–1.95) Confirmed cardiovascular death 1.22% 1.27% 1.14% 0.76 1.11 (0.56–2.21) Confirmed non-cardiovascular death 0.22% 0.14% 0.38% 0.18 0.37 (0.08–1.66) Cause unknown 0.22% 0.28% 0.09% 0.29 2.97 (0.36–24.73) Hospitalisation 27.5% 27.9% 26.7% 0.51 1.06 (0.89–1.27) MI 2.07% 2.39% 1.42% 0.07 1.70 (0.95–3.03) ARC definite scaffold thrombosis 1.10% 1.36% 0.57% 0.04 2.41 (1.00–5.82) TLF 2.70% 3.00% 2.09% 0.13 1.45 (0.89–2.37) TVF 3.98% 4.31% 3.32% 0.18 1.31 (0.88–1.95) MACE 4.33% 4.64% 3.70% 0.22 1.27 (0.87–1.85) Values are mean ± standard deviation (SD) or number and percentage (n, %). *Comparison between off-label and on-label use. The p-values are from Chi-squared test or Mann-Whitney-Wilcoxon test. ARC, academic research consortium; FU, follow up; MACE, major adverse cardiac events; PCI, percutaneous coronary intervention; TLF, target lesion failure; TVF, target vessel failure.

Kaplan-Meyer curve stent thrombosis

Conclusions

The off-label use of BRS compared to confirmed indications appears to be associated with a higher rate of clinical endpoints considering more complex lesions and higher morbidity in this patients' group.

Acknowledgement/Funding

This research was supported by a grant from Abbott Vascular.

P962Follow-up of protected high-risk percutaneous coronary intervention with microaxial Impella pump. Results from the retrospective German Impella Registry

Background

Percutaneous coronary intervention (PCI) presents a relevant alternative to coronary bypass surgery for the treatment of patients with complex coronary artery disease and high perioperative risk. By temporary implantation of a percutaneous ventricular assist devices (pVAD) interventionalists attempt to anticipate the hemodynamic risk of those high-risk patients in a so-called protected PCI. The Impella® system presents the currently most common device for protected PCI and could show hemodynamic stability in earlier trials.

Methods

This study is a retrospective, observational multi-center registry of ten hospitals in Germany. We included patients undergoing protected high-risk PCI with Impella® support. The primary endpoint was defined as major adverse cardiac events (MACE) during a 180-day follow-up and consisted of all-cause mortality, myocardial infarction (MI) and stroke.

Results

Six of the participating hospitals performed a follow-up. In total, 157 patients (80.3% male; mean age 71.8±10.8 years) were included in the present study. Prior to PCI, median left ventricular ejection fraction was 39.0% (25.0%-50.0%) and median SYNTAX-Score I was 33.0 (24.0–40.5). The 180-day follow-up was available for 149 patients (94.9%). Eight patients (5.1%) were lost to follow-up. During the follow-up period, 34 patients (22.8%) suffered from a MACE. A total of 27 patients (18.1%) died. Nine patients (6.0%) sustained a MI, while 4 patients (2.7%) had a stroke.

Kaplan-Meier curves for primary endpoint

Conclusions

Patients undergoing protected high-risk PCI with Impella® support show a good 180-day clinical outcome regarding rates of MACE and mortality. However, a head-to-head comparison of Impella supported patients to protected PCI with other pVADs is pending.

Acknowledgement/Funding

S.B., N.W., F.A.-R., J.-M.S., A.S., R.S., I.A. receive consulting fees/honoraria from Abiomed (Danvers, MA, USA).

[ARENA-Project atrial fibrillation in the Rhein-Neckar region]

Atrial fibrillation (AF) is the most common form of cardiac tachyarrhythmia. It is estimated that in the Rhein-Neckar region approximately 40,000-50,000 out of 2 million people are affected. Due to demographic changes in the near future there will be a significant increase in the prevalence of AF within the next decades. The ARENA project was initiated by the Foundation Institute for Cardiac Infarction Research (IHF) Ludwigshafen in cooperation with cardiological and neurological departments of neighboring hospitals, resident doctors and pharmacies to improve the awareness and care of patients with AF. The particular aim is the prevention of stroke as one of the most dreaded complications. The project focusses on the following three subtopics: interventions, medication, migration. The aim of the intervention project is to raise awareness of AF as a risk factor for stroke and to improve the diagnostic work-up and care for patients with diagnosed or unknown AF. The subproject medication focusses on the adherence of patients with AF to the prescribed antithrombotic medication. To evaluate differences concerning patients with and without a migration background the subproject migration was initiated.

Correction to: Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism

The article Occlusion of left atrial appendage aff ects metabolomic profile:focus on glycolysis, tricarboxylic acid and urea metabolism, written by K. Sattler, M. Behnes, C. Barth, A. Wenke, B. Sartorius, I. El-Battrawy, K. Mashayekhi, J. Kuschyk, U. Hoffmann, T. Papavasiliu, C. Fastner, S. Baumann, S. Lang, X. Zhou, G. Yücel, M. BorggrefeI, Akin, was originally published Online First without open access.

Pitfalls in accelerometer-based measurement of physical activity: The presence of reactivity in an adult population

When a behavior is monitored, it is likely to change, even if no change may be intended. This phenomenon is known as measurement reactivity. We investigated systematic changes in accelerometer-based measures over the days of monitoring as an indicator of measurement reactivity in an adult population. One hundred seventy-one participants from the general population (65% women; mean age = 55 years, range: 42-65 years) wore accelerometers for 7 consecutive days to measure sedentary behavior and physical activity (PA). Latent growth models were used (a) to investigate changes in accelerometer wear time over the measurement days and (b) to identify measurement reactivity indicated by systematic changes in sedentary time (ST), light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Over the measurement days, participants reduced accelerometer wear time by trend (rate of change [b] = -4.7 min/d, P = .051, Cohen's d = .38), increased ST (b = 2.4 min/d, P = .018, d = .39), and reduced LPA (b = -2.4 min/d, P = .015, d = .38). Participants did not significantly reduce MVPA (P = .537). Our data indicated that accelerometry might generate reactivity. Small effects on ST and LPA were found. Thus, the validity of accelerometer-based data on ST and LPA may be compromised. Systematic changes observed in accelerometer wear time may further bias accelerometer-based measures. MVPA seems to be less altered due to the presence of an accelerometer.

Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism

BACKGROUND

Left atrial appendage (LAA) closure (LAAC) by implantation of an occlusion device is an established cardiac intervention to reduce risk of stroke while avoiding intake of oral anticoagulation medication during atrial fibrillation. Cardiac interventions can alter local or systemic gene and protein expression. Effects of LAAC on systemic metabolism have not been studied yet.

OBJECTIVES

We aimed to study the effects of interventional LAAC on systemic metabolism.

METHODS

Products of glycolysis, tricarboxylic acid and urea metabolism were analyzed by ESI-LC-MS/MS and MS/MS using the AbsoluteIDQ™ p180 Kit in plasma of 44 patients undergoing successful interventional LAAC at baseline (T0) and after 6 months (T1).

RESULTS

During follow up, plasma concentrations of several parameters of glycolysis and tricarboxylic acid cycle (TCA) and urea metabolism increased (alanine, hexose, proline, sarcosine), while others decreased (aspartate, glycine, SDMA, serine). Multivariate linear regression analysis showed that time after interventional LAAC was an independent predictor for metabolite changes, including the decrease of SDMA (beta -0.19, p < 0.01) and the increase of sarcosine (beta 0.16, p < 0.01).

CONCLUSIONS

Successful interventional LAAC affects different pathways of the metabolome, which are probably related to cardiac remodeling. The underlying mechanisms as well as the long term effects have to be studied in the future.

[Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease]

Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.

[Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]

BACKGROUND

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy.

MATERIAL AND METHODS

The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016.

RESULTS

A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients.

CONCLUSION

The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

Comparison and outcome analysis of patients with apical and non-apical takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC.

METHODS AND RESULTS

Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P  < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison.

CONCLUSIONS

The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.

[Acute pulmonary embolism and contraindication of anticoagulation : Bedside implantation of a new temporary vena cava inferior filter]

Pulmonary embolism (PE), mostly caused by deep vein thrombosis, is a life-threatening complication in critically ill patients in the intensive care unit. A potential strategy to prevent PE in patients with contraindication for anticoagulant therapy is the implantation of a vena cava filter (VCF), to provide fast and safe PE protection against ascending thrombi. We report the case of a 56-year-old woman with an intracranial hemorrhage, who developed a PE. Because of acute contraindications for anticoagulant therapy, bedside implantation of a new VCF was performed to overcome the period of absolute contraindications for anticoagulation. After explanation, several thrombi were found on the filter.