Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract in patients with left ventricular dilation and/or dysfunction

Left ventricular (LV) dysfunction caused by frequent premature ventricular complexes (PVCs) can be reversed by suppression of PVCs with antiarrhythmic agents or radiofrequency catheter ablation (RFA). However, there is a paucity of data on the efficacy and safety of RFA among the local population. We aimed in this study to evaluate the effect of RFA of frequent PVCs originating from right ventricular outflow tract (RVOT-PVCs) on cardiac function in patients with depressed cardiac function and/or LV dilation. The study included sixteen patients with monomorphic RVOT-PVCs without overt underlying structural heart disease. Frequency of PVCs by 24-h Holter monitoring, left ventricular ejection fraction (LVEF), end-diastolic diameter (LVEDD), end-systolic diameter (LVESD), mitral regurgitation (MR) by echocardiogram and NYHA functional class were evaluated before and 3 and 6 months after RFA. All patients underwent RFA.ResultsThe higher the number of PVCs/24 h, the bigger the LVESD and the lower the EF. Procedural success was achieved in 13 (81%) of the patients with no complications. Six months follow-up after successful ablation, LVEDD decreased significantly (from 56.62 ± 5.87 to 49.23 ± 5.31 mm; p = 0.002), LVESD decreased significantly (from 41.85 ± 7.82 to 33.69 ± 4.66 mm; p = 0.002), LVEF increased significantly (from 46.69 ± 4.92% to 60.54 ± 5.39%; p < 0.001) and NYHA functional class improved in all patients after successful ablation.ConclusionRF catheter ablation of frequent RVOT-PVC has a beneficial effect on cardiac function in patients with depressed cardiac function.It carries a high degree of success and safety. Frequent RVOT-PVCs are burden on LV function even in patients without overt underlying structural heart disease.     

Ablation of unstable ventricular dysrhythmias guided by non contact mapping system among patients with cardiomyopathy in a growing single center experience

We report our local experience in using the non contact mapping system in guiding catheter ablation of unstable/non sustained Ventricular tachycardia (VT) and its short and long term implications.Patients and methodsThis report includes 18 cardiomyopathic patients, 13 males, age 40.5 ± 15 yrs, who presented to our centre with VT that share in common being unstable or non sustained. The patients were subjected to radiofrequency catheter ablation guided by the non contact mapping system.ResultsAcute successful outcome was obtained in 6 out of 8 (75%) patients with scar related VTs (post myocardial infarction and arrhythmogenic right ventricular dysplasia) and 9 of 10 (90%) patients with idiopathic dilated cardiomyopathy. Long term follow up for 6–24 (16 ± 8) months showed recurrence in one case of the scar related group and in two cases of the idiopathic group, so the overall long term success rates were 62.5% vs 70% (P. NS). Regular Echocardiographic showed an improvement of 10–15% in the Ejection Fraction in successful cases of the idiopathic group (Average Post-ablation EF in the idiopathic group of 49 ± 5% vs pre-ablation EF of 41 ± 4% while 42 ± 6 pre Vs 42 ± 7% post ablation in the scar related group) (P < 0.01).ConclusionNon contact mapping guided RF ablation of unstable VT in patients with cardiomyopathy showed good immediate results and long term outcome both in scar related and in idiopathic cardiomyopathy patients. Successful RF ablation of non sustained ventricular dysrhythmias among patients with idiopathic Cardiomyopathy may improve LV dysfunction.     

Value of mitral annular plane systolic excursion in the assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization

BackgroundMitral annular plane systolic excursion (MAPSE) is an M-mode derived echocardiographic marker of left ventricular longitudinal function, the aim of this study is to evaluate the value of MAPSE in assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.MethodsThe study included 50 patients with ischemic cardiomyopathy with ejection fraction (EF) ≤35%, the patients presented to echocardiography laboratory for dobutamine stress echocardiography (DSE) to assess viability and contractile reserve before revascularization, patients with primary valvular disease, and those with significant mitral annular calcifications were excluded from the study. A low dose DSE was done to all patients using standardized incremental infusions of 5, 10, and 20 μg/kg/min and the following parameters were measured at both baseline and peak dose, (EF, wall motion score index(WMSI) and MAPSE). Contractile reserve was measured as the difference between the low dose and baseline values of the EF and WMSI.ResultsThe study included 50 patients aged 55.08 ± 7.15 years, 94% were males, the DSE protocol was complete in all patients without serious side effects. A total of eight hundred segments were analyzed, at baseline 65% were dysfunctional including 31.2% hypokinetic, 28.8% were akinetic, and 5% were dyskinetic. At low dose study 70% of the dysfunctional myocardium showed viability, EF increased significantly from 30.84 ± 4.56 to 42.24 ± 8.15%, p < 0.001, the WMSI reduced significantly from 1.92 ± 0.33 to 1.47 ± 0.39, and MAPSE increased significantly from 1.02 ± 0.23 to 1.30 ± 0.30 mm. MAPSE showed a significant positive correlation with EF at both baseline and low dose study (r = 0.283, p = 0.046 & r = 0.348, p = 0.013) respectively and a significant negative correlation with WMSI at both baseline and low dose study (r = −0.3, p = 0.034 & r = −0.409, p = 0.003), respectively. By ROC curve analysis we found that Δ MAPSE ≥2 mm can predict contractile reserve at Δ EF >10% (AUC = 0.6, sensitivity 67.86, specificity 59.09), and Δ MAPSE ≥1.8 mm can predict contractile reserve at ΔWMSI ≤0.20 (AUC = 0.61, sensitivity 65.5, specificity 75.6).ConclusionsMAPSE is a rapid simple quantitative echocardiographic method that can asses contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.     

First Egyptian experience of Transcatheter Aortic Valve Implantation: Immediate results and one year follow up

BackgroundTrans-catheter Aortic Valve Implantation (TAVI) offers a less invasive modality to manage aortic stenosis (AS) especially in high risk patients. It was not available in Egypt until the end of 2011.AimThe aim of this study is to report immediate and one year follow up results of first TAVI implantations in Egyptian patients.Patients and methodsTen patients with severe symptomatic AS underwent TAVI implantation using Edwards SAPIEN™ and SAPIEN XT™ valves.ResultsThe mean age was 78.6 ± 4.6 years and 5 (50%) were males. The mean Logistic EuroSCORE and EuroSCORE II were 21.9 ± 11.5% and 12.6 ± 7.2%, respectively. Procedural success was achieved in all (100%) patients using SAPIEN™ (n = 8) and SAPIEN XT™ (n = 2) valves. Almost all (n = 9) patients underwent a trans-femoral approach and percutaneous closure devices were used in the last 2 patients. Post procedural NYHA grade (1.3 ± 0.3), aortic valve area (2.0 ± 0.1 cm²) and mean pressure gradient (14.1 ± 2.7 mmHg) were nearly maintained all over the one-year-follow-up period.ConclusionTAVI provides a safe and effective alternative to the surgical AVR in high risk patients with severe symptomatic AS. Financial issues, however, limits its application in developing countries.     

Desnervação renal em doentes com hipertensão arterial resistente: resultados aos seis meses de seguimento

IntroductionIncreased activation of the sympathetic nervous system plays a central role in the pathophysiology of hypertension (HTN). Catheter‐based renal denervation (RDN) was recently developed for the treatment of resistant HTN.AimTo assess the safety and efficacy of RDN for blood pressure (BP) reduction at six months in patients with resistant HTN.MethodsIn this prospective registry of patients with essential resistant HTN who underwent RDN between July 2011 and May 2013, the efficacy of RDN was defined as ≥10 mmHg reduction in office systolic blood pressure (SBP) six months after the intervention.ResultsIn a resistant HTN outpatient clinic, 177 consecutive patients were evaluated, of whom 34 underwent RDN (age 62.7 ± 7.6 years; 50.0% male). There were no vascular complications, either at the access site or in the renal arteries. Of the 22 patients with complete six‐month follow‐up, the response rate was 81.8% (n = 18). The mean office SBP reduction was 22 mmHg (174 ± 23 vs. 152 ± 22 mmHg; p < 0.001) and 9 mmHg in diastolic BP (89 ± 16 vs. 80 ± 11 mmHg; p = 0.006). The number of antihypertensive drugs (5.5 ± 1.0 vs. 4.6 ± 1.1; p = 0.010) and pharmacological classes (5.4 ± 0.7 vs. 4.6 ± 1.1; p = 0.009) also decreased significantly. Of the 24‐hour ambulatory BP monitoring and echocardiographic parameters analyzed, there were significant reductions in diastolic load (45 ± 29 vs. 27 ± 26%; p = 0.049) and in left ventricular mass index (174 ± 56 vs. 158 ± 60 g/m²; p = 0.014).ConclusionIn this cohort of patients with resistant HTN, RDN was safe and effective, with a significant BP reduction at six‐month follow‐up.     

Patterns of serum lipids derangements and cardiovascular risk assessment in patients with primary biliary cholangitis

Introduction and objectivesPrimary biliary cholangitis (PBC) is a chronic cholestatic autoimmune disease that disrupts the cholesterol metabolism. Our aim was to investigate the frequency of dyslipidemias and to evaluate the risk of cardiovascular events in a historic cohort of patients with PBC.PatientsAll patients attended from 2000 to 2009 with histological diagnosis of PBC were included and were compared with healthy controls. The 10-year cardiovascular risk was estimated by the Framingham risk score.ResultsFifty four patients with PBC were included and compared to 106 controls. Differences in total cholesterol (263.8 ± 123.9 mg/dl vs. 199.6 ± 40, p = 0.0001), LDL-cholesterol (179.3 ± 114.8 vs. 126.8 ± 34.7, p = 0.0001), HDL-cholesterol (62.4 ± 36.2 mg/dl vs. 47.3 ± 12.3, p = 0.0001) and triglycerides (149.1 ± 59.1 mg/dl vs. 126.4 ± 55.4, p = 0.001) were found. Hypercholesterolemia (>240 mg/dl) was found in 52.4% of the patients with PBC vs. 11% in the control group, high LDL-cholesterol (160–189 mg/dl) in 45.2% of the patients with PBC vs. 10% in controls and hyperalphalipoproteinemia (HDL-cholesterol >60 mg/dl) in 45.2% of the patients with PBC vs. 16% in controls. The 10-year cardiovascular risk was 5.3% ± 5.9 in the patients with PBC and 4.1% ± 5.7 in the control group (p = 0.723, IC 95% = 0.637–1.104). Only one cardiovascular event (stroke) in a patient with PBC was registered in a mean follow up time of 57.9 ± 36.5 months.ConclusionsMarked derangements in serum lipids and a high frequency of dyslipidemias are found in patients with PBC, however, these do not increase the risk of cardiovascular events.     

Short term effects of sildenafil citrate therapy in secondary pulmonary hypertension

ObjectivesTo study the short term effects of sildenafil citrate therapy in patients with secondary pulmonary hypertension.MethodsForty patients with known symptomatic secondary pulmonary hypertension due to valvular heart disease, chronic thromboembolic disease, chronic obstructive pulmonary disease, interstitial pulmonary fibrosis, and idiopathic dilated cardiomyopathy were included in this phase II study. Patients were allocated in a randomized, placebo controlled design to either sildenafil or placebo for 6 weeks. Baseline and 6 week follow up included assessment of hemodynamic parameters, functional class using the NYHA classification, echocardiographic measurements of pulmonary artery systolic pressure and left ventricular ejection fraction.ResultsThe mean NYHA class at 6 weeks was 2.05 ± 0.4 in the sildenafil group versus 2.6 ± 0.6 in the placebo group, p = 0.02. The mean systolic pulmonary artery pressure significantly decreased in the sildenafil group at 6 weeks (43 ± 4 mmHg), compared to placebo patients (53 ± 7 mmHg), p = 0.02. Ejection fraction was higher in the sildenafil group, 59 ± 12% versus 54 ± 14% in the placebo group, but did not reach statistically significant difference. Sildenafil was well tolerated with minimal side effects.ConclusionOur data suggest that sildenafil therapy may provide benefits to selected patients with pulmonary hypertension secondary to cardiac or pulmonary diseases.     

Efficacy of four different moxifloxacin-based triple therapies for first-line H. pylori treatment

Moxifloxacin has been used in the first-line treatment of Helicobacter pylori infection. The optimal dosage and duration have not been assessed.AimTo evaluate the effectiveness of moxifloxacin, amoxicillin and esomeprazole in four regimens, in previously untreated patients infected by H. pylori.Methods and patientsPatients were randomly assigned to: esomeprazole 20 mg b.i.d., amoxicillin 1 g b.i.d., and one of each of the four following dosages of moxifloxacin: moxifloxacin 400 mg b.i.d. for 10 days (EAM800 × 10), moxifloxacin 400 mg b.i.d. for 7 days (EAM800 × 7), moxifloxacin 400 mg b.i.d. for 5 days (EAM800 × 5), moxifloxacin 400 mg o.i.d. for 10 days (EAM400 × 10). Eradication was assessed by the Urea Breath Test (UBT) 2 months following the end of therapy.ResultsNinety-four, 102, 92 and 105 patients were recruited in EAM800 × 10, EAM800 × 7, EAM800 × 5, and EAM400 × 10 respectively. The eradication rate was for Intention-To-Treat (ITT) and Per Protocol (PP) analyses: EAM800 × 10 group ITT: 90.4%, PP: 94.4%; EAM800 × 7 group ITT: 80.3%, PP: 86.3%; EAM800 × 5 group ITT: 71.4%, PP: 75.2%; EAM400 × 10 group ITT: 80.0%, PP 84.8%. A statistically significant difference was reached between EAM800 × 10 vs. EAM800 × 7 (ITT and PP: P < 0.05), and between EAM800 × 10 vs. EAM800 × 5 (ITT and PP: P < 0.01) and vs. EAM400 × 10 (ITT: P < 0.05; PP: P < 0.04). Thirty patients treated unsuccessfully with EAM800 × 5 and EAM400 × 10 were re-treated with EAM800 × 10 with an eradication rate of 86.7% (ITT) and 92.2% (PP). Nineteen patients with positive UBT after EAM800 × 10 and EAM800 × 7 underwent a second-line rifabutin-based therapy with an eradication rate of 84.2% (ITT and PP).ConclusionA triple therapy with 800 mg of moxifloxacin a day for 10 days is more effective than the same treatment for 5 or 7 days and a treatment with 400 mg of moxifloxacin a day for 10 days for the first-line eradication of H. pylori infection. The high cost of moxifloxacin-based treatment however, may limit its wide use as first-line treatment of H. pylori infection.     

Comparison of left and right atrial appendages anatomy and function in patients with mitral stenosis and sinus rhythm

BackgroundThe left atrial appendage (LAA) has been considered a relatively significant portion of the cardiac anatomy. Transesophageal echocardiography (TEE) is a technique that makes clear imaging of the LAA possible, so that its shape and function can be assessed. Tissue Doppler imaging (TDI) was used recently for the assessment of the contractile function of the left atrial appendage (LAA) and right atrial appendage (RAA).Patients and methodsForty-three patients with pure mitral stenosis (MS) in sinus rhythm were compared to 12 normal individuals only patients with mild and severe mitral stenosis were included. Patients with moderate mitral stenosis were excluded. A transthoracic and a transesophageal echo were performed in all patients. We assessed the LAA anatomy (neck width, length, area). Assessment of LAA function was done by the recording of LAA emptying velocity. Pulsed-wave tissue Doppler imaging (TDI) was positioned at the tip of the LAA and the tip of the RAA to obtain atrial peak systolic (Sm) and diastolic myocardial velocities.ResultsPatients with MS (severe and mild) had a larger left atrial diameter and area than the control {50.5 ± 3.8 & 46.2 ± 4.5 vs 35.4 ± 1.8, and 31.2 ± 3.3 & 26 ± 2.3 vs 19.9 ± 1.4} P-value 0.0001 & 0.0001, respectively and patients with MS (severe and mild) had a higher PASP than the control {50.9 ± 10.5 & 30 ± 7 vs 25.2 ± 1.6} P-value 0.0001. TEE data of patients with MS (severe and mild) had a larger left atrial appendage length, base, and area than the control {(49.8 ± 6.38 & 42 ± 2.5 vs 37.8 ± 2.2), (27.7 ± 3.8 & 23.2 ± 3.1 vs 18 ± 2.5), and (7.6 ± 0.6 & 6.5 ± 0.5 vs 4.6 ± 0.7} P-value 0.0001. Patients with MS (severe and mild) had a significant decrease in atrial peak systolic flow velocities (S wave) than the control (16.1 ± 3.7 & 26.5 ± 0.7 vs 70 ± 13), P-value 0.0001.Also patients with MS (severe and mild) had significant decrease in atrial peak systolic myocardial velocities (Sm wave) of the LAA compared with the control (6.1 ± 1.7 & 12.6 ± 0.3 vs 18.8 ± 1.9), P-value 0.0001. (TDI) flow of the RAA myocardial velocity, patients with mitral stenosis (severe and mild) had a significant decrease in atrial peak systolic myocardial velocities (Sm wave) of the RAA compared with the control (16.5 ± 2.9 & 17.7 ± 1.6 vs 20.1 ± 2.6), P-value 0.0001. SEC was detected in the LAA in 17 patients of the 43 patients with mitral stenosis which represents 39.5% of the patients. All patients with SEC were with severe MS. Patients with SEC had a significant increase in Fc, mean transmitral gradient, PASP, Sm LAA, Sm RAA, LAA area and peak S velocity LAA than patients without SEC. No patient had SEC in the RAA cavity.ConclusionLAA and RAA dysfunction occurred in patients with MS and sinus rhythm due to increase of atrial afterload presented by a decrease in atrial myocardial velocities.     

Should Proximal LAD be treated differently? Insights from a large DES stent registry

BackgroundThe current revascularization treatment recommendation is different according to lesion location and a higher recommendation is given to surgery for proximal LAD (pLAD) lesions over PCI. This is based on previous studies and expert opinion. We aimed to investigate whether indeed there is a difference in outcome with respect to LAD lesion location while using a drug eluting stent (DES).MethodsThe NOBORI-2 trial, enrolled 3067 consecutive patients in 125 centers who were treated with DES for single and multivessel disease. We compared 834 [27.2%] patients who underwent PCI of the pLAD as part of their revascularization, to 2203 [71.8%] patients in which stenting to other lesion(s) but not the pLAD was performed.ResultsThe pLAD group had lower incidence of hypertension, peripheral vascular disease, prior PCI and CABG, but had more lesions treated [1.55 ± 0.8 vs. 1.35 ± 0.6], more stents implanted [1.98 ± 1.2 vs. 1.66 ± 1.0] and longer overall stent length [31.8 ± 20.2 vs. 28.2 ± 17.8 mm].There was no difference in the occurrence of the primary endpoint [cardiac death, myocardial infarction and target lesion revascularization] at 1 or 2 years of follow up between the pLAD and non pLAD [6.0% vs. 4.6%, p = 0.14 and 7.7% vs. 6.6%; p = 0.22, respectively]. The relief from anginal symptoms was similar. Multivariate analysis showed that pLAD location was not a variable that predicted MACE or TLF. Stent thrombosis rate was similar.ConclusionWhen considering PCI with DES, there is no difference in outcome between patients with and without proximal LAD lesions.     

Heart rate manipulation in dilated cardiomyopathy: Assessing the role of Ivabradine

BackgroundHeart rate (HR) reduction is of benefit in chronic heart failure (HF). The effect of heart rate reduction using Ivabradine on various echocardiographic parameters in dilated cardiomyopathy has been less investigated.MethodsOf 187 patients with HF (DCM, NYHA II–IV, baseline HR > 70/min), 125 patients were randomized to standard therapy (beta blockers, ACEI, diuretics, n = 62) or add-on Ivabradine (titrated to maximum 7.5 mg BD, n = 63). Beta-blockers were titrated in both the groups.ResultsAt 3 months both groups had improvement in NYHA class, 6 min walk test, Minnesota Living With Heart Failure (MLWHF) scores and fall in BNP, however the magnitude of change was greater in Ivabradine group. Those on Ivabradine also had lower LV volumes, higher LVEF (28.8 ± 3.6 vs 27.2 ± 0.5, p = 0.01) and more favorable LV global strain (11 ± 1.7vs 12.2 ± 1.1, p = <0.001), MPI (0.72 ± 0.1 vs 0.6 ± 0.1, p = <0.001), LV mass (115.2 ± 30 vs 131.4 ± 35, p = 0.007), LV wall stress (219.8 ± 46 vs 238 ± 54) and calculated LV work (366 ± 101 vs 401 ± 102, p = 0.05). The benefit of Ivabradine was sustained at 6 months follow up. The % change in HR was significantly higher in Ivabradine group (−32.2% vs −19.3%, p = 0.001) with no difference in blood pressure. Resting HR < 70/min was achieved in 96.8% vs 27.9%, respectively in the two groups.ConclusionAddition of Ivabradine to standard therapy in patients with DCM and symptomatic HF and targeting a heart rate < 70/min improves symptoms, quality of life and various echocardiographic parameters.     

Utility of right ventricular Tei-index for assessing disease severity and determining response to treatment in patients with pulmonary arterial hypertension

BackgroundWe sought to evaluate the potential utility of echocardiography-derived morphological and functional right ventricular (RV) variables for assessing disease severity of pulmonary arterial hypertension (PAH) and determining the changes in the patient's hemodynamics in the clinical course.Methods and resultsThis study consisted of 24 normal controls (the control group) and 24 patients with PAH at rest or with exercise (the PAH group) who underwent echocardiography, right heart catheterization, plasma brain natriuretic peptide (BNP) measurement, and six-minute walk distance (6MWD) test. The PAH group had poorer RV echocardiographic variables than the control group. RV Tei-index was more strongly correlated with 6MWD, BNP, cardiac index, mean pulmonary arterial pressure, and pulmonary vascular resistance (PVR) than other RV echocardiography-derived variables including RV end-diastolic areas, RV fractional area change, and tricuspid annular plane systolic excursion. In 16 of the 24 patients who successfully underwent repeated examination during follow up (13.3 ± 4.9 months; range, 5–24 months), PVR decreased from 486 ± 380 dyne s cm⁻⁵ to 346 ± 252 dyne s cm⁻⁵, and RV Tei-index decreased from 0.55 ± 0.30 to 0.42 ± 0.17, and the changes in RV Tei-index were correlated with the concomitant changes in PVR during the clinical course of PAH (r = 0.706, p = 0.002). Tricuspid annular plane systolic excursion and RV fractional area change did not change during the follow up.ConclusionsQuantitative echocardiography revealed that the measurement of RV Tei-index is of great clinical utility for predicting disease severity of PAH and determining the changes in the patient's hemodynamics in the clinical course.     

Characterization of Venezuelan patients with systemic sclerosis: a study in a tertiary hospital in Caracas

ObjectiveThe aim of the study was to investigate the demographic and clinical characteristics of Venezuelan patients with systemic sclerosis (SSc) seen in a tertiary hospital.MethodsConsecutive patients 18 years and older who fulfilled the 2013 ACR/EULAR classification criteria for SSc and who were followed up in the outpatient clinic of the Division of Rheumatology at the Hospital Universitario de Caracas were selected for the study. Demographic and clinical variables were registered at the time of inclusion using a standard protocol.ResultsForty-eight SSc patients were included; 46 (95.8%) were female; the mean age was 55.1 ± 13.7 (mean ± SD) years and all were of Hispanic ethnicity. Thirty-one (64.6%) had limited SSc and 17 (35.4%) had diffuse SSc. The mean duration of disease was 13.4 ± 11.7 (mean ± SD) years, 16.74 ± 12.99 years for limited SSc and 7.52 ± 5.25 years for diffuse SSc (p = 0.0077). Raynaud's phenomenon was the most frequent manifestation (100%), followed by arthritis (68.8%), telangiectasia (60.4%), dyspnea (60.4%), dysphagia (58.3%) and puffy hands (56.3%). The modified Rodnan Skin Score (mRSS) and the frequency of dyspnea were higher in those with diffuse as compared to limited SSc (p = 0.0211 and p = 0.0003, respectively). We performed high-resolution computed tomography (HRCT) of the lungs in 31 patients; 14 (45.2%) had evidence of interstitial lung disease (ILD), 11 (68.8%) with diffuse SSc (p = 0.0052). The most frequent anti-nuclear antibody pattern was nucleolar, accounting for 18 (42.8%) of the cases. Anti-centromere antibodies were present in 16.7% of the cases and were associated with the limited SSc subset (p = 0.0443) and with calcinosis (p = 0.0020). Anti-topoisomerase antibodies were associated with ILD (p = 0.0077).ConclusionsTypical clinical and serological manifestations were present in this sample of Venezuelan patients with SSc, with an expected distribution according to disease subtype. The autoantibody profile allows clinicians to identify those patients with limited forms of the disease and those without pulmonary involvement.     

La técnica de superposición de cúspides en TAVI con dispositivo autoexpandible optimiza la profundidad del implante y reduce la necesidad de marcapasos permanente

Introduction and objectivesThis study aimed to determine the safety and efficacy of modifying the classic implantation technique for aortic transcatheter heart valve (THV) implantation to a cusp-overlap-projection (COP) technique to achieve a higher implantation depth and to reduce the burden of new permanent pacemaker implantation (PPMI) at 30 days. Aortic self-expanding THV carries an elevated risk for PPMI. A higher implantation depth minimizes the damage in the conduction system and may reduce PPMI rates.MethodsFrom March 2017, 226 patients were consecutively included: 113 patients were treated using the COP implantation technique compared with the previous 113 consecutive patients treated using the classic technique. In all patients, implantation depth was assessed by 3 methods (noncoronary cusp to the THV, mean of the noncoronary cusp and the left coronary cusp to the THV, and the deepest edge from the left coronary cusp and the noncoronary cusp to the THV).ResultsThe COP group had a lower implantation depth than the group treated with the classic technique (4.8 mm ± 2.2 vs 5.7 mm ± 3.1; P = .011; 5.8 mm ± 3.1 vs 6.5 mm ± 2.4; P = .095; 7.1 mm ± 2.8 vs 7.4 mm ± 3.2; P = .392). Forty patients (17.7%) required a new PPMI after the 30-day follow-up but this requirement was significantly lower in the COP group (12.4% vs 23%, P = .036). The COP implantation technique consistently protected against the main event (OR, 0.45; 95%CI, 0.21-0.97; P = .043), with similar procedural success rates and complications.ConclusionsThe COP implantation technique is a simple modification of the implantation protocol and provides a higher implantation depth of self-expanding-THV with lower conduction disturbances and PPMI rates.     

Endoscopic band ligation of internal haemorrhoids versus stapled haemorrhoidopexy in patients with portal hypertension

Background and study aimPortal hypertension is common in Egypt as a sequela to the high prevalence of hepatitis C virus and bilharziasis. In portal hypertension internal haemorrhoids are frequently found. The aim of this work was to compare the outcome of endoscopic band ligation (EBL) of symptomatic internal haemorrhoids with that of stapled haemorrhoidopexy (SH) in Egyptian patients with portal hypertension.Patients and methodsIn this study, 26 portal hypertensive patients (with oesophageal and/or fundal varices) with a grade 2–4 internal haemorrhoids who had no coagulation disorders were randomised to treatment by EBL (13 patients) or SH (13 patients) after doing colonoscopy. Symptom scores of bleeding and prolapse were assessed before and after the intervention. Complications were recorded. Patients were followed up for 12 months.ResultsGoligher’s grades of internal haemorrhoids improved significantly (p = 0.018) 12 weeks after SH (from 2.9 ± 0.8 to 0.4 ± 0.5; p = 0.001) and after EBL (from 2.8 ± 0.8 to 1.1 ± 0.8; p = 0.001). Symptom (bleeding and prolapse) scores significantly improved 4 weeks after both EBL (from 1.6 ± 0.8 to 0.6 ± 0.8; p < 0.001 and from 1.6 ± 0.9 to 0.5 ± 0.5; p = 0.002, respectively) and SH (from 1.8 ± 0.8 to 0.2 ± 0.4; p = 0.002 and from 1.5 ± 0.9 to 0.2 ± 0.4; p = 0.001, respectively). The differences after 4 weeks between EBL and SH were not significant (p = 0.168 and p = 0.225). Pain requiring analgesics occurred in five patients (38.5%) after EBL, compared with six (46.2%) after SH (p = 0.691). Minimal bleeding occurred in two patients (15.4%) after EBL but not with SH; urinary retention was observed in one patient after EBL compared with two after SH; and anal fissures were observed in one patient after EBL. During 1-year follow-up, increased frequency of stool occurred in one patient after EBL. Recurrence of symptoms was observed in three patients after EBL and in one after SH.ConclusionFor portal hypertensive patients with internal haemorrhoids and without coagulation disorders SH seems to be superior to EBL. However further studies are needed to evaluate EBL in different grades of cirrhosis.     

Acute myocardial perfusion imaging – A useful tool for evaluation of therapeutic modalities & a predictor of urgent need for revascularization in acute coronary syndromes

We have been evaluating different therapeutic modalities using acute MPI, & we aimed at the use of acute MPI as a predictor of patients in need for urgent revascularization.MethodsA total of 85 patients with ACS were included in our study, 57 males, mean age 52.9 ± 10.6 years, 35% were diabetics, 50% hypertensive, 54% smokers, 30% dyslipidemic & 33% had +ve family history of CAD. Acute MPI was done by SPECT technique using triple head Gamma Camera. Every patient had two sets of images, first set done on admission by injecting 25 mCi Tc^99m SestaMIBI intravenously before initiating therapeutic intervention and acquired within 6 h of injection. Second set of images was acquired 2 days later. Myocardium at risk (MAR) was calculated using 20 segment scoring system from the 1st set of images (scale 0–4/segment). Residual ischemia (RI) was calculated from the second set of images. Salvage index (SI = MAR − RI/MAR × 100) was taken as an end point for successful reperfusion (SI > 30%). All risk factors and MPI parameters were analyzed as independent predictors for the need for urgent revascularization vs. conservative strategy.ResultsPatients were subdivided according to therapeutic modalities used into three groups, group I: (50 pts) received unfractionated heparin, group II: (20 pts) received low molecular weight heparin & group III: (15 pts) received GPIIb/IIIa. There was no statistical difference as regards risk factors, age, sex, & MAR. Salvage index was highest in group II & lowest in group I (39 ± 21% vs. 64 ± 33.6% vs. 58 ± 25%) P = 0.07. Successful reperfusion was achieved in 67.3% in group I & 90% of group II, 86.7% in group III (P = 0.06). Out of 85 pts, 31 patients (group A) were in need for inhospital target vessel revascularization & 54 patients (group B) showed a good response on medical treatment (conservative strategy). Compared to group B, group A had higher values of RI (11 ± 7 vs. 5 ± 4%, P < 0.0001) & lower SI (15 ± 6 vs. 67 ± 24%, P < 0.0001) despite similar MAR (14 ± 7 vs. 15 ± 8) P > 0.05. High SI > 60%, and absence of diabetes (DM) were good predictors for conservative management strategy (specificity 96%); however, SI < 30% as well as presence of DM may recognize patients in need for urgent revascularization (sensitivity 50%) with overall predictive accuracy of 78.8%.ConclusionAcute MPI is a useful tool for evaluating therapeutic interventions. SI > 60% as well as absence of DM could recognize the subset of patients who can be managed conservatively whereas SI < 30% as well as presence of DM may recognize patients in need for urgent revascularization.     

Efficacy and safety of an insulin infusion protocol during and after cardiac surgery

AimPerioperative tight blood glucose (BG) control using insulin therapy after major surgery is a difficult, time-consuming task that also raises some concerns over the risk of severe hypoglycaemia. The aim of the present prospective study was to evaluate the efficacy and safety of an insulin therapy protocol in use at our institution.MethodsA total of 230 consecutive patients (mean ± SD age: 67 ± 11 years; diabetic patients: n = 62) undergoing cardiac surgery (coronary artery bypass grafting: n = 137; 20% off-pump) or intrathoracic aortic (n = 10) surgery were included. BG control was managed according to an insulin therapy protocol, described by Goldberg et al. (2004) [11], in use for 6 months in our intensive care unit. Insulin infusion rate and frequency of BG monitoring were both adjusted according to: (1) the current BG value; (2) the previous BG value; and (3) the current insulin infusion rate. Efficacy was assessed by the percentage of time spent at the target BG level (100–139 mg/dL) intraoperatively and during the first 2 postoperative days (POD).ResultsAll patients received postoperative insulin therapy. Patients spent 57.3% and 69.7% of time within the BG target range on POD 1 and 2, respectively. The percentage of time was significantly higher in nondiabetics than in diabetics. Mean BG measurements per patient intraoperatively, on POD 1 and on POD 2 were 4 ± 1, 10 ± 2 and 7 ± 2, respectively. No patient experienced any severe hypoglycaemic events (BG < 50 mg/dL).ConclusionThis study showed that a BG target of 100–139 mg/dL can be safely achieved with an insulin therapy protocol that can be routinely used in everyday clinical practice.     

The impact of commissural morphology on clinical outcome in patients undergoing percutaneous balloon mitral valvuloplasty

AimWe aimed to evaluate the prognostic value of commissural morphology on immediate and short term outcome after Percutaneous balloon mitral valvuloplasty (PBMV).MethodsThe study included 30 patients with symptomatic mitral stenosis (MS) scheduled for PBMV with these exclusion criteria: left atrial thrombi, High echocardiography score, Moderate to severe mitral regurgitation (MR), Atrial fibrillation (AF) or Calcification. After PBMV, they were randomized into 2 groups: Group I: 12 patients with only opened one commissure and group II: 18 patients with bilateral opened commissures.ResultsFollowing PBMV, the mean mitral valve area (MVA) increased from 0.94 ± 0.19 to 1.86 ± 0.27 cm² in group I & from 0.91 ± 0.18 to 2.29 ± 0.33 cm² in group II (p = 0.001). The mean transmitral gradient (MG) decreased from 21.83 ± 4.1 to 8.08 ± 2.9 mmHg in group I and from 18.28 ± 5 to 5.2 ± 1.76 mmHg in group II (p = 0.003). The MVA was 1.85 ± 0.23 cm² in group I and 2.25 ± 0.31 cm² in group II (p = 0.001) and MG was 8.09 ± 2.90 mmHg in group I and 5.47 ± 1.79 mmHg in group II (p = 0.001). Three month follow-up: there was no patient developed AF, embolization or severe MR. Also, there was no mortality, redo, or surgery.ConclusionWe concluded that degree of commissural opening and MVA are closely related. The complete bilateral commissural opening is associated with better sustained MVA and functional status. Thus, evaluation of the degree of commissural opening can be considered as a complementary measure of the procedural success in PBMV.     

Asymptomatic damage of central nervous system defined by excess level of protein S100B by patients undergoing the radiofrequency ablation of ventricular tachycardia

AimEvaluation of the effect of radiofrequency catheter ablation of ventricular arrhythmias on asymptomatic central nervous system evaluation with the help S100B protein. Furthermore, identification of factors predicting elevation of S100B protein level after ablation.MethodsConsecutive patients undergoing RFA for ventricular arrhythmias between 11/2015 and 8/2016. Protein S100B was evaluated before the procedure, immediately after the procedure, in 8 and 24 h after the procedure. In the case of the excess values of the S100B protein within 24 h after computer tomography (CT) of CNS supplementation and neurological examination.Set of patients23 patients, of which there were 19 men and 4 women aged 62 ± 8. Coronary artery disease with a scar after myocardial infarction 18 patients (78%), 2 patients with dilated cardiomyopathy, 2 patients with idiopathic ventricular tachycardia, 1 patient with non-compact cardiomyopathy.Eject fraction of left ventricle was 29 ± 8%. All patients with implantable cardioverter defibrillator. 3 patients (13%) underwent RFA by combined endo-epicardial approach. By 5 patients (22%) the surgery was performed in general anesthesia.ResultsAt least one excess value of S100B protein was identified by 10 patients (43%). After 24 h, the cut off value of the protein S100B was exceeded by 3 patients (13%). Even in one of these patients, we did not see acute changes on CT of CNS or by neurological examination. Surgery duration, ablation time, necessity for defibrillation during the surgery, intensity of anticoagulation during the surgery were without statistically significant influence on elevation of S100B protein levels.A group of patients with S100B elevation had statistically significantly worse renal functions represented by serum creatinine level (127 ± 41 vs. 100 ± 25 μmol/l, p = 0.02). As another factor that statistically significantly predicted the postablation elevation of the protein S100B the stage of heart failure measured by the levels of NTproBNP (4417 vs 1634 ng/l, p = 0.05) was shown. A statistically significant effect on the elevation of S100B protein in our set was the use of total anesthesia with sevoflurane (p = 0.03).ConclusionThe elevation of the S100B protein after catheter ablation for ventricular arrhythmias is relatively common in our set. We did not identify any macroscopic changes on CT of CNS even by neurological examination.The level of renal insufficiency, the progression of cardiac failure, and the use of inhaled anesthesia with sevoflurane correlate with the amount of S100B as the biomarker of asymptomatic disability of CNS by patients receiving radiofrequency catheter ablation for ventricular arrhythmias.