Serial determination of anthracycline poisoning in children

Dose-related cardiotoxicity limits enthracycline administration in patients with solid tumours or leukaemia. Many patients (70%) would probably benefit by receiving more than a total accumulative dose of 500 mg/m2. As a measure of myocardial function the left ventricular ejection fractions (EF) were determined from serial radionuclide angiograms in 62 children who had at least 3 studies (mean age 8.4 +/- 5.4 years). Seven patients who had clinical evidence of cardiac involvement and/or a marked decline in their EF underwent endmyocardial biopsy (9 x). The EF declined progressively from 63 +/- 7% prior to chemotherapy to 60 +/- 5%, 58 +/- 7% and 54 +/- 7% after low, medium and high-dose anthracycline, respectively in the non-biopsied children vs 58 +/- 4%, 54 +/- 7% and 48 +/- 4% in the biopsied patients. Anthracycline dosage was 129 +/- 42, 307 +/- 68 and 471 +/- 61 mg/m2 and 103 +/- 64, 303 +/- 73 and 536 +/- 93 mg/m2, respectively. The biopsies were obtained at a mean anthracycline dose of 408 mg/m2 when the EF was 46 +/- 5%, and graded according to the modified Billingham score; grade 1 (6 x), 1.5 (2 x) and 2.5 (1 x). A decline in the EF was seen in 89% of our patients throughout their chemotherapy course, with a statistical significance of p less than 0.02 in the biopsied patients after medium dose therapy which was not seen in the non-biopsied children until they were receiving anthracyclines.     

Usefulness of myocardial performance index and biochemical markers for early detection of anthracycline-induced cardiotoxicity in adults

BACKGROUND: Anthracycline therapy is limited by cardiotoxicity. Currently no diagnostic parameter is available allowing ubiquitous and reliable detection of preclinical anthracycline cardiomyopathy and prediction of prognosis. PATIENTS AND METHODS: In 100 consecutive patients receiving anthracycline-based chemotherapy serial measurements of left ventricular systolic and diastolic function, Tei index (a Doppler echocardiographic parameter of global ventricular function), cardiac troponin T (cTnT) and NT-probrain natriuretic peptides (BNP) at baseline and during 1-year follow-up were performed. RESULTS: Mean ejection fraction (LVEF) significantly decreased immediately after completion of anthracycline therapy (mean dose 226.1 +/- 8.3 mg/m(2)) und further declined during follow-up (65.9 +/- 0.6% Vs. 61.6 +/- 0.7%; P < 0.001), while mean E/A ratio decreased after 6 months (P = 0.05). No patient presented with cardiac symptoms. The Tei index increased after therapy in the majority of patients (78.8%) compared with pre-therapy values indicating myocardial alteration in more patients than previously recognized. cTnT levels did not exceed the upper limit of the normal range in any patient. Seven patients had low-level elevations of cTnT. Only one of these patients developed a concomitant decrease in LVEF. Mean N-terminal-pro-BNP (NT-proBNP) levels did not significantly change after anthracycline administration. However, in 13 patients (15.3%) a marked, transient increase of NT-proBNP was obtained after the first anthracycline cycle without cardiac dysfunction presumably due to altered cardiac loading conditions during chemotherapy. CONCLUSION: Low to moderate doses of anthracyclines resulted in subclinical myocardial alteration in more patients than so far noticed. Clinical implications of increased Tei index remain to be determined in long-term. Our results do not support that assessment of cTnT or BNP levels may safely replace serial echocardiographic evaluation of systolic and diastolic function for the monitoring of anthracycline cardiotoxicity.     

Effectiveness of late gadolinium enhancement to improve outcomes prediction in patients referred for cardiovascular magnetic resonance after echocardiography

Background

Echocardiography (echo) is a first line test to assess cardiac structure and function. It is not known if cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) ordered during routine clinical practice in selected patients can add additional prognostic information after routine echo. We assessed whether CMR improves outcomes prediction after contemporaneous echo, which may have implications for efforts to optimize processes of care, assess effectiveness, and allocate limited health care resources.

Methods and results

We prospectively enrolled 1044 consecutive patients referred for CMR. There were 38 deaths and 3 cardiac transplants over a median follow-up of 1.0 years (IQR 0.4-1.5). We first reproduced previous survival curve strata (presence of LGE and ejection fraction (EF) < 50%) for transplant free survival, to support generalizability of any findings. Then, in a subset (n = 444) with contemporaneous echo (median 3 days apart, IQR 1–9), EF by echo (assessed visually) or CMR were modestly correlated (R² = 0.66, p < 0.001), and 30 deaths and 3 transplants occurred over a median follow-up of 0.83 years (IQR 0.29-1.40). CMR EF predicted mortality better than echo EF in univariable Cox models (Integrated Discrimination Improvement (IDI) 0.018, 95% CI 0.008-0.034; Net Reclassification Improvement (NRI) 0.51, 95% CI 0.11-0.85). Finally, LGE further improved prediction beyond EF as determined by hazard ratios, NRI, and IDI in all Cox models predicting mortality or transplant free survival, adjusting for age, gender, wall motion, and EF.

Conclusions

Among those referred for CMR after echocardiography, CMR with LGE further improves risk stratification of individuals at risk for death or death/cardiac transplant.     

Deferiprone does not protect against chronic anthracycline cardiotoxicity in vivo

Anthracycline cardiotoxicity ranks among the most severe complications of cancer chemotherapy. Although its pathogenesis is only incompletely understood, "reactive oxygen species (ROS) and iron" hypothesis has gained the widest acceptance. Besides dexrazoxane, novel oral iron chelator deferiprone has been recently reported to afford significant cardioprotection in both in vitro and ex vivo conditions. Therefore, the aim of this study was to assess whether deferiprone 1) has any effect on the anticancer action of daunorubicin and 2) whether it can overcome or significantly reduce the chronic anthracycline cardiotoxicity in the in vivo rabbit model (daunorubicin, 3 mg/kg i.v., weekly for 10 weeks). First, using the leukemic cell line, deferiprone (1-300 microM) was shown not to blunt the antiproliferative effect of daunorubicin. Instead, in clinically relevant concentrations (>10 microM), deferiprone augmented the antiproliferative action of daunorubicin. However, deferiprone (10 or 50 mg/kg administered p.o. before each daunorubicin dose) failed to afford significant protection against daunorubicin-induced mortality, left ventricular lipoperoxidation, cardiac dysfunction, and morphological cardiac deteriorations, as well as an increase in plasma cardiac troponin T. Hence, this first in vivo study changes the current view on deferiprone as a potential cardioprotectant against anthracycline cardiotoxicity. In addition, these results, together with our previous findings, further suggest that the role of iron and its chelation in anthracycline cardiotoxicity is not as trivial as originally believed and/or other mechanisms unrelated to iron-catalyzed ROS production are involved.     

The relation between quantitative right ventricular ejection fraction and indices of tricuspid annular motion and myocardial performance.

BACKGROUND: Assessment of right ventricular (RV) function remains challenging because of complex RV chamber geometry and a paucity of easily derived and objective functional methods. METHODS: Visual 2-dimensional echocardiographic estimates of RV ejection fraction (EF), tricuspid annular plane systolic excursion, Doppler tissue imaging, and myocardial performance index (MPI) were compared with biplanar Simpson's rule RV EF in 101 consecutive patients. Data were analyzed using simple linear regression and receiver operating characteristic curves. RESULTS: RV EF was significantly correlated with tricuspid annular plane systolic excursion (r = 0.48, P <.0001), Doppler tissue imaging peak systolic velocity (r = 0.45, P <.0001), and MPI (r = -0.38, P =.006). Using a Simpson's RV EF < 50%, the sensitivity, specificity, and positive and negative predictive values of tricuspid annular plane systolic excursion < 1.5 cm were 59%, 94%, 71%, and 89%; of Doppler tissue imaging peak systolic velocity < 10 cm/s were 59%, 92%, 67%, and 89%; and of MPI < 0.40 were 100%, 35%, 29%, and 100%, respectively. The area under the receiver operating characteristic curves was similar for the 3 indices. CONCLUSIONS: Measurements of tricuspid annular motion are easy to obtain, correlate with Simpson's RV EF, and have a high specificity and negative predictive value for detecting abnormal RV systolic function; and the MPI, although not specific, has high sensitivity and negative predictive value for detecting abnormal RV systolic function.     

Prognostic value at 5 years of microvascular obstruction after acute myocardial infarction assessed by cardiovascular magnetic resonance

Background

Early and late microvascular obstruction (MVO) assessed by cardiovascular magnetic resonance (CMR) are prognostic markers for short-term clinical endpoints after acute ST-elevation myocardial infarction (STEMI). However, there is a lack of studies with long-term follow-up periods (>24 months).

Methods

STEMI patients reperfused by primary angioplasty (n = 129) underwent MRI at a median of 2 days after the index event. Early MVO was determined on dynamic Gd first-pass images directly after the administration of 0.1 mmol/kg bodyweight Gd-based contrast agent. Furthermore, ejection fraction (EF, %), left ventricular myocardial mass (LVMM) and total infarct size (% of LVMM) were determined with CMR. Clinical follow-up was conducted after a median of 52 months. The primary endpoint was defined as a composite of death, myocardial re-infarction, stroke, repeat revascularization, recurrence of ischemic symptoms, atrial fibrillation, congestive heart failure and hospitalization.

Results

Follow-up was completed by 107 patients. 63 pre-defined events occurred during follow-up. Initially, 74 patients showed early MVO. Patients with early MVO had larger infarcts (mean: 24.9 g vs. 15.5 g, p = 0.002) and a lower EF (mean: 39% vs. 46%, p = 0.006). The primary endpoint occurred in 66.2% of patients with MVO and in 42.4% of patients without MVO (p < 0.05). The presence of early MVO was associated with a reduced event-free survival (log-rank p < 0.05). Early MVO was identified as the strongest independent predictor for the occurrence of the primary endpoint in the multivariable Cox regression analysis adjusting for age, ejection fraction and infarct size (hazard ratio: 2.79, 95%-CI 1.25-6.25, p = 0.012).

Conclusion

Early MVO, as assessed by first-pass CMR, is an independent long-term prognosticator for morbidity after AMI.     

紫杉类药物用于可手术乳腺癌的辅助化疗

目的:蒽环类药物化疗方案中加入紫杉类药物能否提高可手术乳腺癌患者的生存获益.方法:选择2006年1月至2009年1月的初治乳腺癌患者391例,分为不含紫杉类药物组(CEF组138例,CTF组97例),含紫杉类药物组(TEC组98例,TTC组58例).以无病生存作为第一观察终点,以死亡作为第二观察终点.结果:中位随访47个月,不含紫杉类药物组患者中无病生存(DFS)占90.1％,总生存(0S)为97.7％,含紫杉类药物化疗组患者中DFS为90.0％,OS为97.6％,均无明显统计学意义.含紫杉类药物组有较高的Ⅲ度以上白细胞下降率和心脏损害发生率(P＜0.01).结论:蒽环类方案中加入紫杉类药物未显著改善患者DFS和OS.     

Severe traumatic brain injury in pediatric patients: treatment and outcome using an intracranial pressure targeted therapy—the Lund concept

Objective This study evaluated the outcome of treatment according to the Lund concept in children with severe traumatic brain injury and investigated whether the preset goals of the protocol were achieved.Design and setting A two-center retrospective study in neurointensive care units at university hospitals.Patients Forty-one children with severe traumatic brain injury from blunt trauma and arriving at hospital within 24 h after injury. Median age was 8.8 years (range 3 months–14.2 years), Glasgow Coma Scale 7 (3–8), and Injury Severity Score 25 (16–75). All children had pathological findings on initial computed tomography. All developed intracranial hypertension, and survivors required intensive care longer than 72 h.Interventions Treatment according to the principles of the Lund concept.Measurements and results Neurosurgery was required in 46% of the children. Survival rate was 93% and favorable outcome (Glasgow Outcome Score 4 or 5) was 80% at long-term follow-up (median 12 months postinjury, range 2.5–26). The preset physiological and biochemical goals were achieved in over 90% of observations.Conclusions Treating pediatric patients with severe traumatic brain injury, according to the Lund concept, results in a favorable outcome when the protocol is followed.     

Stress-only Tc-99m myocardial perfusion imaging in an emergency department chest pain unit

Background

Stress-only myocardial perfusion imaging (MPI) saves time by eliminating rest imaging, which is important for emergency department (ED) throughput but has not been studied in an ED population.

Study Objective

To determine the prognosis of a normal stress-only MPI study compared to a normal rest-stress MPI and establish its effectiveness in an ED setting.

Methods

All patients evaluated in the ED over 6.5 years who underwent a stress-only technetium-99m gated MPI were compared to those who had a rest-stress study. All-cause mortality was determined using the Social Security Death Index. Survival was analyzed in patients with normal and abnormal MPI results.

Results

A total of 4145 studies (2340 stress-only, 1805 rest-stress) were performed. Patients’ average age was 57.9 years, 38.5% were male, and most had an intermediate or low pretest risk of coronary artery disease (87.7%). Average follow-up was 35.9 ± 20.9 months. In patients with normal perfusion, at 1 year of follow-up there were 11 deaths in the stress-only group (0.5% 1-year mortality), and 13 deaths in the rest-stress cohort (1.1% 1-year mortality). At the end of follow-up, the stress-only group had a lower all-cause mortality (p < 0.0001) and similar risk adjusted all-cause mortality (p = 0.10) than the rest-stress cohort. Patients with abnormal perfusion demonstrated the expected differential prognosis based on total perfusion deficits in both groups.

Conclusions

A normal stress-only MPI study has a benign 1-year prognosis similar to a rest-stress study when performed in the ED. The ability to triage patients more rapidly and reduce radiation exposure represents an attractive alternative for low-risk patients.     

Cardioprotective effects of a novel iron chelator, pyridoxal 2-chlorobenzoyl hydrazone, in the rabbit model of daunorubicin-induced cardiotoxicity

Iron chelation is the only pharmacological intervention against anthracycline cardiotoxicity whose effectiveness has been well documented both experimentally and clinically. In this study, we aimed to assess whether pyridoxal 2-chlorobenzoyl hydrazone (o-108, a strong iron chelator) can provide effective protection against daunorubicin (DAU)-induced chronic cardiotoxicity in rabbits. First, using the HL-60 leukemic cell line, it was shown that o-108 has no potential to blunt the antiproliferative efficacy of DAU. Instead, o-108 itself moderately inhibited cell proliferation. In vivo, chronic DAU treatment (3 mg/kg weekly for 10 weeks) induced mortality (33%), left ventricular (LV) dysfunction, a troponin T rise, and typical morphological LV damage. In contrast, all animals treated with 10 mg/kg o-108 before DAU survived without a significant drop in the LV ejection fraction (63.2 +/- 0.5 versus 59.2 +/- 1.0%, beginning versus end, not significant), and their cardiac contractility (dP/dt(max)) was significantly higher than in the DAU-only group (1131 +/- 125 versus 783 +/- 53 kPa/s, p < 0.05), which corresponded with histologically assessed lower extent and intensity of myocardial damage. Although higher o-108 dose (25 mg/kg) was well tolerated when administered alone, in combination with DAU it led to rather paradoxical and mostly negative results regarding both cardioprotection and overall mortality. In conclusion, we show that shielding of free intracellular iron using a potent lipophilic iron chelator is able to offer a meaningful protection against chronic anthracycline cardiotoxicity. However, this approach lost its potential with the higher chelator dose, which suggests that iron might play more complex role in the pathogenesis of this disease than previously assumed.     

Radiofrequency ablation of neuroendocrine liver metastases—the Middlesex experience

Background Current treatment options for neuroendocrine liver metastases are not widely applicable or not that effective. Image-guided thermal ablation offers the possibility of a minimally invasive, albeit palliative, treatment that decreases tumor volume, preserves most of the normal liver, and can be repeated several times. We report our experience with image-guided thermal ablation in 25 patients with unresectable liver metastases.Methods Since 1990 we have treated 189 tumors at 66 treatment sessions in 25 patients (12 female, 13 male; median age, 56 years; age range, 26–78 years). Thirty treatments were performed with a solid-state laser, and 36 treatments were performed with radiofrequency ablation. All but one treatment was performed percutaneously under image guidance. Sixteen patients had metastases from carcinoid primaries, three from gastrinoma, two from insulinoma, and four from miscellaneous causes. Fourteen of 25 had symptoms from hormone secretion.Results Imaging follow-up was available in 19 patients at a median of 21 months (range, 4–75 months). There was a complete response in six patients, a partial response in seven, and stable disease in one; hence, tumor load was controlled in 14 of 19 patients (74%). Relief of hormone-related symptoms was achieved in nine of 14 patients (69%). The median survival period from the diagnosis of liver metastases was 53 months. One patient with end-stage cardiac disease died after a carcinoid crisis. There were eight (12%) complications: five local and three distant, four major and four minor.Conclusions As a minimally invasive, readily repeatable procedure that can be used to ablate small tumors, preferably before patients become severely symptomatic, radiofrequency ablation can provide effective control of liver tumor volume in most patients over many years.     

Diagnosis of malignant cardiac disease by endomyocardial biopsy

Among oncology patients, endomyocardial biopsy has been used primarily for the evaluation of anthracycline cardiotoxicity. In addition, however, endomyocardial biopsy may be useful for the detection of malignant cardiac neoplasms. Between 1982 and 1989, metastatic involvement of the heart was diagnosed by endomyocardial biopsy in seven patients at our institution. All except one of these patients were older than 50 years of age and had dyspnea as an initial symptom, and all had a known malignant lesion. Results of endomyocardial biopsy confirmed cardiac involvement by a hematologic malignant lesion in four patients and metastatic melanoma in two patients. In one patient, who had a history of breast cancer and lymphoma, a metastatic neoplasm of uncertain differentiation was observed. Myocyte damage was evident in endomyocardial biopsy specimens from two of the four patients with hematologic malignant disease. Endomyocardial biopsy was performed to confirm the possibility of metastatic involvement in five patients; in the other two, endomyocardial biopsy was performed to determine whether anthracycline cardiotoxicity was present, and metastatic involvement was unanticipated.     

Potential clinical impact of cardiovascular magnetic resonance assessment of ejection fraction on eligibility for cardioverter defibrillator implantation

Background

For the primary prevention of sudden cardiac death, guidelines provide left ventricular ejection fraction (EF) criteria for implantable cardioverter defibrillator (ICD) placement without specifying the technique by which it should be measured. We sought to investigate the potential impact of performing cardiovascular magnetic resonance (CMR) for EF on ICD eligibility.

Methods

The study population consisted of patients being considered for ICD implantation who were referred for EF assessment by CMR. Patients who underwent CMR within 30 days of echocardiography were included. Echocardiographic EF was determined by Simpson’s biplane method and CMR EF was measured by Simpson’s summation of discs method.

Results

Fifty-two patients (age 62±15 years, 81% male) had a mean EF of 38 ± 14% by echocardiography and 35 ± 14% by CMR. CMR had greater reproducibility than echocardiography for both intra-observer (ICC, 0.98 vs 0.94) and inter-observer comparisons (ICC 0.99 vs 0.93). The limits of agreement comparing CMR and echocardiographic EF were – 16 to +10 percentage points. CMR resulted in 11 of 52 (21%) and 5 of 52 (10%) of patients being reclassified regarding ICD eligibility at the EF thresholds of 35 and 30% respectively. Among patients with an echocardiographic EF of between 25 and 40%, 9 of 22 (41%) were reclassified by CMR at either the 35 or 30% threshold. Echocardiography identified only 1 of the 6 patients with left ventricular thrombus noted incidentally on CMR.

Conclusions

CMR resulted in 21% of patients being reclassified regarding ICD eligibility when strict EF criteria were used. In addition, CMR detected unexpected left ventricular thrombus in almost 10% of patients. Our findings suggest that the use of CMR for EF assessment may have a substantial impact on management in patients being considered for ICD implantation.     

左室扭转运动联合高敏肌钙蛋白评估蒽环类药物的早期心肌毒性

  目的   应用三维斑点追踪成像技术获取左室扭转运动相关参数联合血清高敏肌钙蛋白(Hs-cTnT),评估乳腺癌术后蒽环类化疗药物早期心肌毒性的发生。   方法   82例蒽行环类药物化疗的乳腺癌术后患者,于化疗前(Ⅰ组)、化疗2周期(Ⅱ组)、化疗4周期(Ⅲ组)、化疗6周期(Ⅳ组)获取Hs-cTnT、左室扭转运动参数及常规三维参数,比较各参数对于评价早期心肌毒性的敏感度,分析左室扭转运动与Hs-cTnT的相关性。   结果   4组左室扭转运动参数(左室扭转角度峰值、左室扭矩)依次减低(P < 0.05)。左室扭转角度峰值及左室扭矩的曲线下面积分别为0.954、0.912,且具有高特异性和高敏感度。各组血清Hs-cTnT测值小于正常值,但随药物剂量累计而升高(P < 0.05);Pearson相关性分析表明,化疗周期中左室扭转运动参数与血清Hs-cTnT浓度呈负相关关系(左室扭转角度峰值:r=-0.467,P < 0.001;左室扭矩:r=-0.419,P < 0.001)。   结论   左室扭转运动能够早期监测左室心肌功能的改变,评估蒽环类化疗药物致乳腺癌术后患者的心肌损伤。      

超声心动图评价缺血性心脏病左室功能

目的 采用心肌功能指数(myocardial performance index MPI)评估缺血性心脏病左心室功能的作用，探讨MPI的应用、影响因素及存在的不足。方法 缺血性心脏病患72例，健康40例，测量EF、E／A、IRT和MPI，并做比较分析。结果 缺血性心脏病患的E／A比值增高，IRT延长，EF明显下降，MPI明显增高。结论 MPI可以敏感地、全面地评估心脏的收缩和舒张功能。     

常规超声心动图对蒽环类化疗药物致心脏毒性的诊断价值

目的:探讨常规超声心动图对蒽环类化疗药物所致心脏毒性的诊断价值。方法:选取2014年2月至2017年6月在我院接受蒽环类药物化疗的乳腺癌术后患者136例,给予吡柔比星+环磷酰胺+多西他赛方案化疗6个周期。疗程结束后,根据患者是否发生心脏毒性分为心脏毒性组(N=48)和无心脏毒性组(N=76),对比患者化疗前后的超声心动图参数,分析常规超声心动图参数在早期心脏毒性诊断中的价值。结果:心脏毒性组TAPSE、E/A和E/a,值显著低于无心脏毒性组(P0.05)。ROC曲线分析,TAPSE、E/A和E/e'对应的曲线下面积分别为0.917(0.874,0.962)、0.902(0.853,0.957)、0.845(0.823,0.921)。TAPSE的截断值为20.78 mm、E/A的截断值为1.19、E/e'的截断值为8.59,Youden指数分别为0.842、0.761、0.712。结论:常规超声心动图在蒽环类药物心脏毒性诊断中具有一定价值。     

Prognosis of patients aged 80 years and over admitted in medical intensive care unit

Objective To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over.Design Prospective cohort study.Setting A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.Patients A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.Measurements and main results Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1–2.6) and severe functional limitation (HR 1.7; 95% CI 1.2–2.6). The IADL was excellent or good for 56% of the surviving patients.Conclusion Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.     

Effects of a single, 24-hour, low-dose intravenous dobutamine infusion on left ventricular myocardial performance index in congestive heart failure: A prospective, nonrandomized study

Background:

Dobutamine, a predominantly beta-adrenergic sympathomimeticagent, is used for improving left ventricular (LV) systolic performance with different dosing regimens in patients with congestive heart failure (CHF). Myocardial performance index (MPI) is an indicator of LV global function that is correlated with LV end-diastolic pressure, and it is increased in CHF.

Objective:

The purpose of this study was to examine the effects of a single, 24-hour, low-dose, IV dobutamine infusion on LV systolic and diastolic function and on MPI in CHF as an indicator of LV global function, as well as the adverse effects (AEs) of the infusion.

Methods:

This prospective, nonrandomized study was conducted at theDepartment of Cardiology, Baskent University Hospital, Ankara, Turkey. Adult patients with LV ejection fraction (EF) <35%, sinus rhythm, and symptomatic CHF were treated using a standard protocol for at least 4 weeks. At the end of this period, patients with symptomatic CHF and EF <35% underwent echocardiography that included measuring isovolumic relaxation and contraction times (IRT and ICT, respectively) and LV ejection time (ET), and calculating LV MPI using the formula MPI = (IRT + ICT)/ET Dobutamine 2.5 μg/kg · min was then infused intravenously for 24 hours. Echocardiography was repeated 24 hours later and values were compared with preinfusion data. Patients were observed and monitored for CHF symptoms and AEs for 24 hours.

Results:

Forty-three patients were enrolled in the study, and 31 (22 men,9 women; mean [SD] age, 67.55 [11.78] years) continued after the 4-week standard-treatment period. Mean (SD) heart rate (74.93 [20.15] vs 80.23 [13.74] bpm, respectively), systolic blood pressure (129.00 [19.23] vs 126.67 [23.79] mm Hg), and diastolic blood pressure (75.80 [11.26] vs 74.96 [8.30] mm Hg) were statistically similar before and after the infusion. The mean (SD) end-diastolic volume was statistically similar to the preinfusion value (215.87 [76.74] vs 211.08 [65.51] mL); however, the mean (SD) end-systolic volume was significantly reduced (163.80 [63.86] vs 146.74 [53.12] mL; P = 0.01). Mean (SD) EF (25.33% [7.77%] vs 30.45% [7.63%]; P = 0.001) and stroke volume (SV) (54.92 [22.30] vs 63.59 [23.91] mL; P = 0.04) increased significantly. The mean (SD) early:late diastolic flow velocity (E/A ratio) (1.58 [1.36] vs 1.65 [1.27]), IRT (107.03 [35.37] vs 100.42 [34.32] ms), ICT (96.61 [34.27] vs 86.35 [44.80] ms), ET (240.65 [33.28] vs 243.48 [33.54] ms), and MPI (0.81% [0.28%] vs 0.78% [0.31%]) did not change significantly after dobutamine infusion. No AEs were observed.

Conclusions:

In this study of adult patients with symptomatic CHF, a single, 24-hour, low-dose, IV dobutamine infusion (2.5 μg/kg · min) was associated with decreased LV end-systolic volume and increased SV and EF However, LV diastolic function parameters, isovolumic time intervals, ET, and MPI were statistically similar to preinfusion values. The infusion was well tolerated.     

Ruptured abdominal aortic aneurysm: endovascular treatment

Background This report describes our preliminary experience in endovascular management of 25 ruptured abdominal aortic aneurysms (rAAAs).Methods In the past 3 years we treated 46 patients who had rAAA, and 25 (54.3%) were treated with an endovascular approach. Patients’ mean age was 76 ± 9 years. The diagnosis was confirmed by computed tomographic angiography in 23 patients (92%). Mean aneurysm diameter was 73 ± 17 mm. We used an infrarenal bifurcated device in 17 patients (68%), a suprarenal bifurcated in four patients (16%), and an aortomonoiliac graft in four patients (16%). Overall, nine patients (36%) required intensive care. Every patient underwent radiologic follow-up according to the Eurostar register, with concomitant evaluation of the D-dimer level (cut-off <200 μg/L) as a biological marker for endoleaks.Results The primary technical success rate was 100%. Overall in-hospital mortality rate was 20%. Mean hospitalization was 7 days (range, 3–30), and mean follow-up was 7 months. One occlusion (4%) of the iliac limb and two type II endoleaks (8%) occurred. The mean D-dimer level in type I endoleak was 1045 μg/L (range, 459–2021).Conclusions In our experience, endovascular management of rAAA is feasible and safe and produces better results than conventional surgery, provided the morphology is suitable and the procedure is carried out by an experienced endovascular team.     

Novel mortality‐predicting index at diagnosis can effectively predict all‐cause mortality in patients with antineutrophil cytoplasmic antibody‐associated vasculitis

BackgroundThis study investigated whether the inflammation prognostic index (IPI) and the mortality predicting index (MPI) at diagnosis could predict all‐cause mortality in patients with antineutrophil cytoplasmic antibody (ANCA)‐associated vasculitis (AAV).MethodsWe included 223 AAV patients and reviewed their medical records. Clinical and laboratory data and AAV‐specific indices at diagnosis were assessed. The IPI was calculated as neutrophil‐to‐lymphocyte ratio (NLR) × C‐reactive protein to albumin ratio (CAR). Here, we newly developed an MPI (NLR × CAR × monocyte counts).ResultsThe mean age of 223 patients (122 MPA, 57 GPA and 44 EGPA patients) was 59 years. The rate of mortality was 11.2%. Using the receiver operator characteristic curve for all‐cause mortality, the cut‐offs were calculated as NLR: 3.22, CAR: 3.25, IPI: 18.53 and MPI: 8367.82. In the univariable Cox hazard analysis, age, gender, smoking history, BVAS, FFS and over the cut‐off of each index showed statistical significance. As the indices share at least two mutual variables, the multivariable analysis was conducted four times based on each index. An IPI ≥18.53 (HR 3.162) and MPI ≥8367.82 (HR 3.356) were significantly associated with all‐cause mortality.ConclusionsThis study developed a novel indicator, MPI, that uses the existing NLR and CAR indices and proved that it could predict all‐cause mortality in AAV patients.