Characteristics of patients with improvement or worsening in renal function during treatment of acute decompensated heart failure

Worsening renal function (RF) and improved RF during the treatment of decompensated heart failure have traditionally been thought of as hemodynamically distinct events. We hypothesized that if the pulmonary artery catheter-derived measures are relevant in the evaluation of cardiorenal interactions, the comparison of patients with improved versus worsening RF should highlight any important hemodynamic differences. All subjects in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial limited data set with admission and discharge creatinine values available were included (n = 401). No differences were found in the baseline, final, or change in pulmonary artery catheter-derived hemodynamic variables, inotrope and intravenous vasodilator use, or survival between patients with improved versus worsening RF (p = NS for all). Both groups were equally likely to be in the bottom quartile of cardiac index (p = 0.32), have a 25% improvement in cardiac index (p = 0.97), or have any worsening in cardiac index (p = 0.90). When patients with any significant change in renal function (positive or negative) were compared to those with stable renal function, strong associations between variables such as a reduced cardiac index (odds ratio 2.2, p = 0.02), increased intravenous inotrope and vasodilator use (odds ratio 2.9, p <0.001), and worsened all-cause mortality (hazard ratio 1.8, p = 0.01) became apparent. In contrast to traditionally held views, the patients with improved RF and those with worsening RF had similar hemodynamic parameters and outcomes. Combining these groups identified a hemodynamically compromised population with significantly worse survival than patients with stable renal function. In conclusion, the changes in renal function, regardless of the direction, likely identify a population with an advanced disease state and a poor prognosis.     

Identification of Hemodynamically Unstable Arrhythmias Using Subcutaneous Photoplethysmography

Hemodynamic Assessment Using Photoplethysmography . Introduction: Determination of hemodynamic status is central to arrhythmia management in the inpatient setting. In contrast, therapy decisions in implantable cardioverter defibrillators (ICDs) are based exclusively on the arrhythmia's electrical signature. Hemodynamic sensing in ICDs would allow tailoring of therapy according to perfusion status. Subcutaneous photoplethysmography (PPG) is an attractive technology for this application because it responds to changes in arterial pressure and can be readily incorporated into the housing of implanted devices. This study evaluated the accuracy of PPG in identifying hemodynamically unstable simulated arrhythmias in an animal model. Methods and Results: Rapid atrial and ventricular pacing was used to simulate arrhythmias in an acute preparation of 7 healthy dogs. Aortic pressure and subcutaneous PPG were simultaneously recorded. Simulated arrhythmias were defined as hemodynamically unstable if aortic pressure decreased by ≥15 mmHg, marginally unstable if pressure decreased by 5–15 mmHg, and hemodynamically stable if pressure either increased or decreased by no more than 5 mmHg. An average of 56 arrhythmias were simulated in each animal. Changes in pressure and PPG output were highly correlated, with correlation coefficient of 0.7–0.9. Subcutaneous PPG identified hemodynamically unstable episodes with a sensitivity of 100% for 6 subjects and 80% for 1 subject. Specificity was more than 90% for 6 subjects and was 50% for 1 subject. Conclusions: Subcutaneous PPG detects hemodynamically unstable simulated arrhythmias in an acute canine preparation. If successfully validated in humans, this technology may allow ICD therapy to be specifically tailored according to the hemodynamic status of the arrhythmia. (J Cardiovasc Electrophysiol, Vol. 21, pp. 448–454, April 2010)     

Safety of nitrate withdrawal in angina-free and hemodynamically stable patients with coronary artery disease

STUDY OBJECTIVES: To assess the consequences of nitrate withdrawal in angina-free and hemodynamically stable coronary patients. DESIGN: Prospective, open, intervention study. SETTING: Cardiology outpatient clinic of a university-affiliated municipal hospital. PATIENTS: Angina-free patients who were hemodynamically stable for at least 3 months before study onset were enrolled. They were all regularly receiving nitrates for symptom control. Those with significant reasons to avoid stopping nitrates, such as heart failure (ejection fraction <35%) or high BP (> 160 mm Hg systolic and/or > 100 mm Hg diastolic), and noncompliant patients were excluded. INTERVENTIONS: After providing informed consent and undergoing an exercise test (whenever possible), the participants were randomized to abruptly discontinue (study group) or continue (control group) nitrate treatment. Follow-up continued for at least 3 months after study entry. MEASUREMENTS AND RESULTS: Eighty patients were randomized to the study group and 40 patients to the control group (mean age [+/- 1 SD], 65.5 +/- 11 years and 66.1 +/- 10.9 years, respectively; p = not significant). The first month, eight study patients (10%) had a recurrence of anginal symptoms, compared with one control subject (2.5%) [p = not significant]. All eight patients responded promptly and favorably to the resumption of nitrate administration. CONCLUSIONS: Nitrate administration can be safely discontinued in angina-free and hemodynamically stable coronary patients who receive this medication on a regular basis. If relapse of anginal symptoms occurs, it will be within 1 month following nitrate withdrawal, and will resolve satisfactorily with reinstatement of treatment.     

Challenges in the diagnosis of acute pulmonary embolism

The state of the art of diagnostic evaluation of hemodynamically stable patients with suspected acute pulmonary embolism was reviewed. Diagnostic evaluation should begin with clinical assessment using a validated prediction rule in combination with measurement of D-dimer when appropriate. Imaging should follow only when necessary. Although with 4-slice computed tomography (CT) and 16-slice CT, the sensitivity for detection of pulmonary embolism was increased by combining CT angiography with CT venography, it is not known whether CT venography increases the sensitivity of 64-slice CT angiography. Methods to reduce the radiation exposure of CT venography include imaging only the proximal leg veins (excluding the pelvis) and obtaining discontinuous images. Compression ultrasound can be used instead. In young women, radiation of the breasts produces the greatest risk of radiation-induced cancer. It may be that scintigraphy is the imaging test of choice in such patients, but this pathway should be tested prospectively. A patient-specific approach to the diagnosis of pulmonary embolism can be taken safely in hemodynamically stable patients to increase efficiency and decrease cost and exposure to radiation.     

H?ufigkeit, Diagnostik und Therapie von Herzrhythmusst?rungen in der Schwangerschaft

Atrial premature beats are frequently diagnosed during pregnancy (PR), supraventricular tachycardia (SVT) less frequently. For acute therapy, electrical DC-cardioversion with 50–100 J is indicated in all unstable patients (pts). In stable SVT, the initial therapy includes vagal maneuvers to terminate breakthrough tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the drug of first choice and may safely terminate the arrhythmia. Ventricular premature beats are also frequently present during PR and benign in most pts, while life-threatening ventricular tachyarrhythmias (sustained ventricular tachycardia (VT), ventricular flutter (VFlut), ventricular fibrillation (VF)) are observed less frequently. Electrical DC cardioversion is necessary in all pts with a hemodynamically unstable situation and life-threatening ventricular tachyarrhythmias; in hemodynamically stable pts, initial therapy with ajmaline, procainamide or lidocaine is indicated. In pts with syncopal VT, VF, VFlut or aborted sudden death, an implantable cardioverter-defibrillator is indicated. In pts with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of PR.     

Perioperative Transfusion Triggers for Red Blood Cells

Perioperative transfusion triggers for red blood cell (RBC) transfusion include physiologic signs of inadequate oxygenation of the entire organism or a specific organ, hemoglobin (Hb) concentration and logistic aspects such as experience of anesthesiologists and surgeons, predictability and magnitude of blood loss and time required for a Hb determination and RBC delivery. At a Hb concentration <6 g/dL a RBC transfusion may be given, however, if the patient is hemodynamically stable one may opt not to transfuse. With Hb concentrations between 6 g/dL and 10 g/dL physiologic signs of inadequate oxygenation decide on RBC transfusion. In absence of hypovolemia signs of inadequate oxygenation include tachycardia and hypotension, an O2 extraction>50%, a a mixed-venous O2 partial pressure <4.3 kPa (32 mmHg), a decrease of O2 consumption >10% (not otherwise explained) and signs of locally deficient oxygenation such as myocardial ischemia. At Hb concentrations >10 g/dL, RBC transfusions are rarely, if ever, indicated.     

Comparison of clinical characteristics and prognosis in Taiwanese patients with coronary vasospastic angina pectoris without significant fixed coronary artery disease versus patients with significant fixed coronary artery disease and either stable angina pectoris or acute coronary syndromes

BACKGROUND: Limited information is available comparing the clinical characteristics and prognosis for patients with coronary vasospastic angina in the absence of hemodynamically significant coronary artery disease (CAD) (defined as >50% stenosis) versus patients with significant fixed CAD presenting with either stable angina pectoris (SAP) or acute coronary syndromes (ACS). METHODS: Patients who underwent cardiac catheterization for suspected ischemic heart disease between August 1999 and February 2003 were followed clinically. For patients without hemodynamically significant CAD, a provocation test for coronary vasospasm was undertaken using a step-wise dose of intracoronary ergonovine administration. RESULTS: A total of 1134 patients were enrolled in the final analysis and stratified into 4 diagnostically distinct groups: control group (n = 239; mild CAD without coronary vasospasm); vasospasm group (n = 284; coronary vasospastic angina pectoris without hemodynamically significant CAD); SAP group (n = 110; hemodynamically significant CAD with SAP); ACS group (n = 501; hemodynamically significant CAD with ACS). Comparison of these 4 groups revealed that the ACS patients were more likely to be male, current smokers, and have hypercholesterolemia. In addition, this group had a significantly higher incidence of typical angina pectoris, 3-vessel CAD, and lower left ventricular ejection fraction. Between-group comparison revealed that vasospasm patients had a significantly higher incidence of early morning angina pectoris. Multivariate analysis showed that current smoking was the most independent risk factor associated with the diagnosis of coronary vasospastic angina pectoris in patients without hemodynamically significant CAD. During a median follow-up period of 49 months, recurrent angina pectoris was noted in patients from the control (n = 6; 3%), SAP (n = 9; 8%), vasospasm (n = 30, 11%), and ACS groups (n = 92; 18%); with nonfatal myocardial infarction identified during follow-up in the SAP (n = 5; 5%), vasospasm (n = 3; 1%), and ACS groups (n = 37; 7%). In addition, 29 and 3 cardiac deaths occurred in the ACS and SAP groups, respectively, whereas there were no such mortalities in the control and vasospasm groups. CONCLUSIONS: Early morning angina pectoris and cigarette smoking were the most common clinical characteristics in patients with coronary vasospasm. These patients had an excellent prognosis despite the possibility of recurrences of vasospastic angina pectoris.     

Characteristics of patients presenting to emergency department for primary atrial fibrillation or flutter at an academic medical center

ObjectiveIn the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations.MethodsWe performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale.ResultsA total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted.ConclusionDeveloping a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care.     

The future of continuous glucose monitoring: closed loop

Improvements in accuracy of real-time continuous glucose monitoring facilitate the development of closed-loop systems consisting of a continuous glucose monitor, a control algorithm, and an insulin pump. Closed-loop systems can be divided according to the way meal delivery is handled as "fully closed-loop" or "closed-loop" with meal announcement systems. Depending on the subcutaneous (sc) or intravenous (iv) body interface, three major types of closed-loop systems are recognised, (i) sc sensing and sc delivery system, (ii) the iv sensing and intraperitoneal delivery system, and (iii) the iv glucose sensing and iv insulin delivery system. Given the current research focus, this review centres on the sc-sc closed-loop approach, which has the greatest potential for a near-future commercial exploitation as recognised by the JDRF Artificial Pancreas Project. Other approaches utilising intraperitoneal or intravenous sensing/delivery are also discussed. Closed-loop systems may revolutionise diabetes management but their introduction is likely to be gradual starting from simpler applications such as hypoglycaemia prevention or overnight glucose control progressing to more complex approaches such as 24/7 glucose control. The most important question is what is achievable with existing technologies and when the first generation of closed-loop systems will find its way into clinical practice.     

Relationship between successful ablation sites and the scar border zone defined by substrate mapping for ventricular tachycardia post-myocardial infarction

INTRODUCTION: It is unknown if identification of scar border zones by electroanatomical mapping correlates with successful ablation sites determined from mapping during ventricular tachycardia (VT) post-myocardial infarction (MI). We sought to assess the relationship between successful ablation sites of hemodynamically stable post-MI VTs determined by mapping during VT with the scar border zone defined in sinus rhythm. METHODS AND RESULTS: Forty-six patients presenting with hemodynamically stable, mappable monomorphic VT post-MI and who had at least one such VT successfully ablated were prospectively included in the study. In each patient, VT was ablated by targeting regions during VT that exhibited early activation, +/- isolated mid-diastolic potentials, and concealed entrainment suggesting a critical isthmus site. Prior to ablation, a detailed sinus-rhythm CARTO voltage map of the left ventricle was obtained. A voltage <0.5 mV defined dense scar. Successful VT ablation sites were registered on the sinus voltage map to assess their relationship to the scar border zone. Of the 86 VTs, 68% were successfully ablated at sites in the endocardial border zone. The remaining VTs had ablation sites within the scar in (18%), in normal myocardium (4%), and on the epicardial surface (10%). There were no significant differences in VT recurrence amongst the different groups. CONCLUSION: Successful ablation sites of hemodynamically stable, monomorphic VTs post-MI are often located in the scar border zone as defined by substrate voltage mapping. However, in a sizable minority, ablation sites are located within endocardial scar, epicardially, and even in normal myocardium.     

Effectiveness and safety of the thrombolytic therapy for acute pulmonary thromboembolism: results of a multicenter registry in the Japanese Society of Pulmonary Embolism Research

OBJECTIVE: To assess the effectiveness and safety of thrombolytic treatment for acute pulmonary thromboembolism (APTE), especially in the hemodynamically stable patients with right ventricular afterload stress. METHODS AND RESULTS: In a total of 221 patients with APTE, the association between thrombolytic treatment and the clinical outcomes were investigated. Thrombolysis was given to 121 patients (Thrombolytic Group), and the remaining 100 patients were treated with anticoagulation alone (Anticoagulation Group). In both patients with prolonged shock and patients who were hemodynamically stable without right ventricular afterload stress, the rate of death and recurrence of APTE in Anticoagulation Group were similar to those in Thrombolytic Group. In patients with right ventricular afterload stress, better outcomes were observed in Thrombolytic Group than in Anticoagulation Group, although the difference did not reach statistical significance. There was no significant difference in the rate of major bleeding episode between these two groups. CONCLUSION: Our results suggested that performing thrombolytic treatment in APTE patients with right ventricular afterload stress should be considered even in Japan.     

Effects of High and Low Shock Energies on Sinus Electrograms Recorded via Integrated and True Bipolar Nonthoracotomy Lead Systems

Effects of Shock Energies on Electrograms. Introduction: The purpose of this investigation was to prospectively evaluate the voltage- and time-dependent characteristics of a biphasic defibrillator discharge on the amplitude of the rate sensing electrogram recorded from two “integrated” and one true bipolar nonthoracotomy lead system. Prolongation of redetection time has been noted after a failed first shock with nonthoracotomy lead systems. However, prospective evaluation of the time- and voltage-dependent effects of biphasic shocks on electrogram amplitude with clinically utilized lead systems has not been systematically performed. Methods and Results: Five- then 30-J R wave synchronous biphasic discharges were delivered during the supraventricular rhythm through three nonthoracotomy lead systems (Medtronic Transvene, Ventritex TVL, and CPI Endotak C 60 Series). The R wave amplitude was measured immediately postshock and for up to 1 minute. Amplitude changes were compared with reshock baseline value. A 5-J discharge had minimal effect on the R wave amplitude recorded from the three lead systems; however. 30 J resulted in significant diminution in R wave amplitude recorded from the integrated bipolar leads (in the Endotak lead to a greater extent than the TVL lead) with minimal effects on the Transvene lead. Following a 30-J discharge, the time constant for R wave recovery was 4.2, 14.9, and 15.3 seconds for Transvene. TVL, and Endotak 60 leads, respectively. Conclusion: There are voltage- and time-dependent reductions in postshock R wave amplitude. Integrated bipolar systems appear more affected than the “true” bipolar lead evaluated. This may he due in part, to lead design, distance of distal defibrillating surface from rate sensing cathode, and the incorporation of the defibrillating surface as the rate sensing anode. The influence of postshock R wave diminution on subsequent redetection remains speculative but may have implications for subsequent lead development.     

Complete heart block in late presentation of inferior STEMI successfully treated with percutaneous coronary intervention

A 55-year-old female presented with 4-day history of fatigue and exertional shortness of breath. A late presentation inferior ST elevation myocardial infarction (STEMI) was diagnosed based on ST elevation in the inferior leads of electrocardiography and elevated cardiac troponin T (TnT). She developed complete heart block 1 day after admission to the hospital and remained hemodynamically stable. She was taken to the catheterization laboratory for a temporary pacing wire insertion. Coronary angiogram at the same time showed an occluded right coronary artery at the mid-section. The lesion was successfully opened. Within 24 hours, the patient's heart rhythm returned to sinus with first-degree atrioventricular block (AVB), thus avoiding the need for a permanent pacemaker. Current guidelines recommend medical management for late presentation hemodynamically stable STEMI of more than 72 H onset. Current ACC/AHA/HRS Pacemaker Guidelines recommend reperfusion strategy for acute presentation inferior STEMI associated with AVB. However, no clear strategy exists in the case of late presentation inferior STEMI with advanced AVB. Our case report suggests that late coronary intervention could be a management strategy in such a scenario in order to avoid a permanent pacemaker.     

A hemodynamically responsive antitachycardia system. Development and basis for design in humans

Current automatic implantable cardioverter-defibrillators detect tachyarrhythmias primarily by rate-only algorithms and cannot adequately distinguish hemodynamically stable from unstable tachyarrhythmias. The responses of right atrial (mean) and right ventricular pressures (mean, systolic, diastolic, and pulse) to 64 induced and paced supraventricular and ventricular tachyarrhythmias were studied in 10 patients (left ventricular ejection fraction of 32 +/- 6%) to develop an algorithm capable of differentiating stable from unstable rhythms. Tachyarrhythmias were defined as hemodynamically unstable when mean arterial pressure decreased by 25 mm Hg or more during 15 seconds. Mean right atrial, right ventricular systolic, and right ventricular pulse pressures were found to be useful in distinguishing the hemodynamic significance of a tachyarrhythmia. A combined detection algorithm was developed that identified a hemodynamically unstable rhythm when the heart rate was 150 beats/min or more and mean right atrial pressure increased by 4 mm Hg or more and right ventricular systolic pressure decreased by 5 mm Hg or more during 15 seconds. This algorithm was then applied to the next 20 consecutive patients (left ventricular ejection fraction of 34 +/- 4%) and compared with the current rate-only algorithm (heart rate of 150 beats/min or more) in 143 tachyarrhythmias, and the sensitivity and specificity for detection of hemodynamically unstable tachyarrhythmias were determined. The rate-only detection algorithm had 100% sensitivity but only 68% specificity for detection of unstable tachyarrhythmias, whereas the combined rate-mean right atrial pressure-right ventricular systolic pressure detection algorithm had sensitivity and specificity of 100%. Therefore, the performance of an antitachycardia system may be significantly improved by detection algorithms that integrate hemodynamic and rate criteria.     

New therapeutic approaches in pulmonary embolism

Pulmonary embolism as a part of venous thromboembolic disease has a broad spectrum of clinical presentations from minimal disease to life-threatening right heart failure. Therapy has to be guided by the risk associated with the individual clinical state of the patient. As long as hemodynamics are entirely stable, anticoagulation is given in order to prevent early or late recurrence, thereby allowing for endogeneous thrombolysis and recovery. In hemodynamically instable patients, i.e. patients under cardiopulmonary resuscitation or in shock, there is the need for a rapid reduction of thrombus mass in order to restore right ventricular function. Systemic thrombolysis is the most feasible modality to reduce the thrombus burden of the pulmonary circulation in the short term. For hemodynamically stable patients with right ventricular dysfunction as assessed by echocardiography, there is still some controversy as to whether thrombolysis improves the long-term outcome. At the least, thrombolysis may positively modify the short-term course of acute disease in patients with an extremely low risk of bleeding. When the acute phase has been overcome, secondary prophylaxis with vitamin K antagonists has to be given. The duration of secondary prophylaxis requires an individual assessment of both the risk of recurrence and the risk of bleeding. In the near future, new anticoagulant drugs such as direct thrombin and factor Xa inhibitors will offer new treatment modalities for the acute phase as well as for secondary prophylaxis.     

Rescue percutaneous repair of ischemic acute severe mitral regurgitation

Acute severe mitral regurgitation (MR) because of secondary left ventricular impaired regional contractility can present with severe acute heart failure, associated with a high risk for rapid decompensation, pulmonary edema and cardiogenic shock. Frequently, in these highly unstable patients, surgical risk can be prohibitive. Evidence for percutaneous repair of acute MR is scarce, but a few case series show that this approach could be safe and effective for bailing out hemodynamically unstable patients.We report a case of an 84-year-old man with acute ischemic severe MR post-acute myocardial infarction (MI), who remained hemodynamically unstable despite coronary revascularization, positive pressure non-invasive ventilation, vasodilator therapy and intra-aortic balloon pump (IABP) support. In heart team discussions, he was considered a high risk surgical candidate. We decided on rescue off-label percutaneous mitral valve repair with a MitraClip device (Abbott Vascular, Santa Clara, California), with good clinical result, allowing weaning from the supports and discharge seven days after the procedure. At one-year follow-up, the patient maintained a MV repair results and had a good functional status. In unstable patients with acute ischemic MR, percutaneous MV repair could be a rescue therapeutic option to consider, allowing hemodynamic compensation with potential persistent MR improvement up to one-year follow-up.     

Fragments de balle dans le septum interventriculaire : faut-il opérer à tout prix ?

IntroductionCardiac gunshot injuries are fatal and very challenging to manage for surgeons. Unfortunately, there is no consensus regarding the management of these patients.Case presentationWe report an unusual case of a cardiac injury after an indirect gunshot to the heart. The 59 years-old male was hemodynamically stable which allowed us to do further investigations revealing a bullets fragment in the interventricular septum without other complication. Conservative management was decided with a careful regular follow-up.ConclusionCardiac gunshot injuries must be managed aggressively in hemodynamically unstable patients. In stable patients, further investigations can be done to allow decision-making.     

Gerinnungshemmende Therapie der Lungenembolie

The aims of anticoagulant therapy for pulmonary embolism are an improved prognosis, rapid recovery of cardiopulmonary function, avoidance of thrombopulmonary recurrences, as well as the prevention of chronic pulmonary hypertension. For hemodynamically stable patients, unfractionated or low molecular weight heparin can be used in the initial therapy, overlapping with coumarin treatment. For hemodynamically unstable patients, thrombolysis is more appropriate than heparin treatment. The value of thrombolysis for patients with submassive pulmonary embolism and a disturbance of right ventricular function is unclear. The increased risk of hemorrhage under thrombolysis is an indication for the effective use of heparin for hemodynamically stable patients, even though an echocardiogram shows right ventricular disturbance. Patients with hemodynamic instability and cardiogenic shock appears to have a better prognosis if treated with the catheter fragmentation of centrally localized emboli in combination with thrombolysis.     

T wave alternans for predicting adverse effects of amiodarone in a patient with dilated cardiomyopathy

An implantable cardioverter defibrillator (ICD) was used in a 62-year-old man with dilated cardiomyopathy (DCM) because of hemodynamically intolerable ventricular tachycardia (VT). Amiodarone was administered after a second episode of ICD discharge. Three weeks later, incessant VT appeared, and DC discharge failed to terminate it. Microvolt T wave alternans (TWA), measured by a spectral method, was observed in this patient with and without amiodarone administration. The onset heart rate with TWA was lower and the alternans voltage was higher with amiodarone than without it. The effects of amiodarone appeared to be related to the exacerbation of VT and an increased defibrillation threshold. TWA might be useful in predicting the proarrhythmic effects of amiodarone in similar cases.     

Left ventricular function after elective aneurysmectomy

Employing rest and exercise first-pass radionuclide angiography before and 3 months after surgery, we studied patients with hemodynamically stable left ventricular aneurysm (LVA) undergoing both coronary artery bypass surgery to relieve angina pectoris and elective aneurysmectomy. There were 15 patients, 14 men and 1 woman with a mean age of 54 +/- 7 years. All patients had anterior and/or apical LVA. After surgery the postexercise mean left ventricular ejection fraction (LVEF) for the whole group improved significantly (p less than 0.004) compared with the preoperative value, but the resting LVEF did not change. The duration of exercise improved (p less than 0.01) after surgery, but not the double product. However, based upon the preoperative LVEF response to exercise, two groups were seen: Group A (n = 5) had greater than or equal to 5% increase in their LVEF with exercise versus Group B (n = 10), who had less than 5% increase or a decrease in their LVEF. Postoperatively, Group A decreased their LVEF with exercise and failed to improve exercise capacity or double product. Postoperatively, Group B increased the LVEF by greater than or equal to 5% as well as increasing exercise capacity (p less than 0.01), and double product (p less than 0.03). Group A had lower preoperative LVEF than Group B (p less than 0.01) and larger LVA. Patients with hemodynamically stable LVA who require coronary artery bypass surgery for angina should not have aneurysmectomy. The presence of hemodynamically stable LVA is not a contraindication to deriving benefit from myocardial revascularization.