TNF-α, myocardial perfusion and function in patients with ST-segment elevation myocardial infarction and primary percutaneous coronary intervention

Aims

To characterize the time course of tumor necrosis factor-α (TNF-α) serum levels along with myocardial perfusion and contractile function in patients with ST-segment elevation myocardial infarction (STEMI) and successful primary percutaneous coronary intervention (PCI).

Methods

Serum levels of TNF-α, interleukin 6 (IL-6), and C-reactive protein (CRP) were measured in 42 patients with STEMI before, one and 6?days after successful PCI. Myocardial perfusion was assessed by contrast-enhanced echocardiography (ceEcho), contractile function by unenhanced two-dimensional (2DE) and real-time three-dimensional echocardiography. In a subset of 18 patients, infarct size was quantified by late gadolinium enhancement cardiovascular magnetic resonance imaging (LGE-CMR) on day six.

Results

TNF-α serum levels were in the upper normal range within the first 12?h from symptom onset and increased continuously until day six, while IL-6 and CRP increased subsequently with a peak on day one after STEMI. Serum TNF-α on day one after PCI correlated with perfusion defects, wall motion abnormalities, and infarct size (ceEcho: r?=?0.52, p?=?0.005; 2DE: r?=?0.56, p?=?0.002; LGE-CMR: r?=?0.83–0.86; p?p?=?0.006, adjusted R ² 0.638).

Conclusion

Our data reflect the clinical significance of early TNF-α elevation in patients with STEMI and primary PCI (Controlled Clinical Trials number, NCT00529607).     

Influence of abciximab on evolution of left ventricular function in patients with non-ST-segment elevation acute coronary syndromes undergoing PCI after clopidogrel pretreatment: lessons from the ISAR-REACT 2 trial

Background

Abciximab reduced the combined endpoint of death, myocardial infarction (MI) and target vessel revascularization in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing percutaneous coronary intervention (PCI) with stent implantation after a 600-mg loading dose of clopidogrel. The aim of the present study was to investigate the impact of abciximab on the evolution of left ventricular ejection fraction (LVEF) in these patients.

Methods

The current study included 1,158 patients enrolled in the randomized, double-blind ISAR-REACT 2 (the Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) trial who had paired angiograms obtained at baseline and 6?C8?months after randomization. Of them, 586 patients received abciximab and 572 patients received placebo. The primary outcome analysis was LVEF at 6?C8-month follow-up.

Results

Baseline LVEF was comparable in patients assigned to abciximab or placebo (53.2?±?12.6 vs. 53.7?±?12.1%; P?=?0.393). At 6?C8-month follow-up angiography, there was no difference in LVEF between the abciximab and placebo groups (55.4?±?11.5 vs. 55.8?±?11.2%; P?=?0.743). Subgroup analysis of patients with elevated baseline troponin (>0.03???g/L) also revealed comparable LVEF at follow-up in both treatment groups (P?=?0.527). The multivariate analysis identified age, arterial hypertension, prior MI, prior coronary artery bypass graft surgery, baseline LVEF, MI at 30?days and repeat PCI as independent correlates of follow-up LVEF.

Conclusion

Although abciximab reduced the 30-day and 1-year incidence of major adverse cardiac events in patients with NSTE-ACS undergoing primary PCI after pre-treatment with a 600-mg loading dose of clopidogrel, the agent did not improve or impact on the evolution of LVEF over 6?C8?months of follow-up.     

Effects of intracoronary injection of autologous bone marrow-derived stem cells on natriuretic peptides and inflammatory markers in patients with acute ST-elevation myocardial infarction

Background

Intracoronary administration of autologous bone marrow stem cells (BMC) has been shown to result in a subtle improvement of global left ventricular ejection fraction after ST-elevation myocardial infarction (STEMI), but the overall benefits of BMC therapy are still unclear. We studied the influence of intracoronary injections of BMC on levels of natriuretic peptides and inflammatory mediators, which are well established prognostic biomarkers, in patients with STEMI.

Methods

In this randomized, double-blind study, consecutive patients with an acute STEMI treated with thrombolysis followed by PCI 2?C6?days after STEMI, were randomly assigned to receive either intracoronary BMC or placebo medium into the infarct-related artery. Blood samples were drawn for biochemical determinations.

Results

From baseline to 6?months, there was a significant decrease in the levels of N-terminal probrain natriuretic peptide (NT-proBNP), interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) in the whole patient population (P?<?0.001 for all). However, no difference was observed between the BMC group (n?=?39) and the placebo group (n?=?39) in the change of the levels of NT-proANP (median ?54 vs. +112?pmol/L), NT-proBNP (?88 vs. ?115?pmol/L) or inflammatory markers IL-6 (?3.86 vs. ?5.61?pg/mL), hsCRP (?20.29 vs. ?22.36?mg/L) and tumor necrosis factor ?? (?0.12 vs. ?0.80?pg/mL) between baseline and 6?months.

Conclusion

Intracoronary BMC therapy does not appear to exert any significant effects on the secretion of natriuretic peptides or inflammatory biomarkers in STEMI patients.     

Platelet inhibition and GP IIb/IIIa receptor occupancy by intracoronary versus intravenous bolus administration of abciximab in patients with ST-elevation myocardial infarction

Background

In patients with ST-elevation myocardial infarction (STEMI), direct intracoronary bolus administration of the glycoprotein (GP) IIb/IIIa receptor antagonist abciximab is associated with a reduction in infarct size, better myocardial salvage, less microvascular obstruction and improved myocardial blush grade as compared to intravenous bolus injection, presumably caused by higher local drug concentrations leading to a more pronounced inhibition of platelet aggregation. We investigated whether there are differences in the degree of GP IIb/IIIa receptor occupancy and platelet inhibition in blood drawn from the coronary sinus (CS) shortly after intracoronary versus intravenous abciximab bolus administration.

Methods

A total of 16 patients with acute STEMI undergoing primary percutaneous coronary intervention within 12?h of symptom onset underwent blood sampling from the CS before, immediately after and 30?min after abciximab bolus administration (intracoronary bolus: n?=?8 patients; intravenous bolus: n?=?8 patients).

Results

Immediately after bolus application, GP IIb/IIIa receptor occupancy in CS blood was significantly higher in patients who received direct intracoronary bolus injection compared to administration via a peripheral vein (intracoronary bolus: 93.5% [IQR 92.7?C95.4]; intravenous bolus: 74.0% [IQR 17.6?C94.0], p?=?0.04). The degree of platelet inhibition was also markedly higher with intracoronary compared to intravenous dosing. At late sampling after 30?min no significant differences were found between groups for both platelet reactivity and GP IIb/IIIa receptor occupancy.

Conclusions

Acutely, direct intracoronary bolus injection resulted in a more pronounced local inhibition of platelet function and a higher degree of GP IIb/IIIa receptor occupancy as compared to standard intravenous bolus injection.     

Is intravascular ultrasound beneficial for percutaneous coronary intervention of bifurcation lesions? Evidence from a 4,314-patient registry

Background

Coronary bifurcations remain a challenging lesion subset for percutaneous coronary intervention (PCI). It is unclear whether intravascular ultrasound (IVUS) guidance can improve PCI results in bifurcations. We aimed to compare IVUS-guided PCI versus standard PCI in a large registry of patients undergoing PCI for bifurcations in the drug-eluting stent era.

Methods

A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between January 2002 and December 2006 at 22 centers. The primary end-point was the long term rate of major adverse cardiac events [MACE, i.e. death, myocardial infarction or target lesion revascularization (TLR)].

Results

A total of 4,314 patients were included, 226 (5.2%) undergoing IVUS-guided PCI, and 4,088 (94.8%) standard PCI. Early (30-day) outcomes were similar in the two groups, with MACE in 1.3 versus 2.1%, respectively, death in 0.9 versus 1.0%, and stent thrombosis in 0 versus 0.6% (all p?>?0.05). After 24?±?15?months, unadjusted rates of MACE were 17.7 versus 16.4%, with death in 2.7 versus 4.9%, myocardial infarction in 4.4 versus 3.7%, TLR in 15.0 versus 12.3%, and stent thrombosis in 3.1 versus 2.7% (all p?>?0.05). Even at multivariable Cox proportional hazard analysis with propensity score adjustment, IVUS was not associated with any statistically significant impact on the risk of MACE, death, myocardial infarction, TLR (neither on the main branch nor on the side branch), or stent thrombosis (all p?>?0.05).

Conclusions

Despite a sound rationale to choose stent size, optimize stent expansion and guide kissing inflation, IVUS usage during PCI for coronary bifurcation lesions was not associated with significant clinical benefits in this large retrospective study.     

Appraising the impact of left ventricular ejection fraction on outcomes of percutaneous drug-eluting stenting for unprotected left main disease: insights from a multicenter registry of 975 patients

Background

Despite the well-known prognostic impact of systolic dysfunction in unselected patients undergoing percutaneous coronary intervention (PCI), limited data are available on its current predictive role after PCI for unprotected left main disease (ULM). We thus appraised the prognostic role of left ventricular ejection fraction (LVEF) in patients undergoing PCI for ULM with drug-eluting stents (DES).

Methods

Consecutive eligible subjects were retrospectively enrolled in a national registry. Patients were divided into three groups: LVEF?<?30%, LVEF 30?C45%, and LVEF?>?45%. Relevant baseline and outcome data were compared with bivariate and multivariable tests.

Results

A total of 975 subjects was included (LVEF?<?30%: 46, LVEF 30?C45%: 208, LVEF?>?45%: 721). Patients with LVEF?<?30% had several other unfavorable clinical features, including older age and higher EuroSCORE. Adverse event rates were different already at 7?days (p?=?0.012 for all-cause death and p?=?0.015 for major adverse cardiac events [MACE]), with even more significant trends up to 30?days and at long-term (p?<?0.001 for death, and p?<?0.001 for MACE). After a median of 18?months, risk of death totaled 39 versus 13 versus 8% (p?<?0.001) and risk of MACE 44 versus 24 versus 22% (p?=?0.003). Multivariable analyses showed however that reduced LVEF was not an independent predictor of adverse events at any time-point.

Conclusions

Whereas reduced LVEF is apparently a significant predictor of adverse events after PCI with DES for ULM, its prognostic impact is mostly due to clustering with other adverse features.     

Efficacy and safety of a high loading dose of clopidogrel administered prehospitally to improve primary percutaneous coronary intervention in acute myocardial infarction: the randomized CIPAMI trial

Objectives

To compare a loading dose of 600?mg clopidogrel given in the prehospital phase versus clopidogrel administered only after the diagnostic angiogram in patients with STEMI scheduled for primary PCI.

Background

The optimal time and dose for the initiation of clopidogrel therapy in patients with STEMI scheduled for primary PCI has not been studied in prospective randomized trials.

Methods

The primary efficacy endpoint was the TIMI 2/3 patency of the infarct-related artery in the diagnostic angiography immediately prior to PCI.

Results

We randomized 337 patients to prehospital (n?=?166) loading dose versus standard therapy (n?=?171). The time interval between initiation of clopidogrel therapy and diagnostic angiography was 47?min. TIMI 2/3 patency before PCI was not different between the groups (49.3 vs. 45.1%, P?=?0.5). We observed a trend towards a reduction of the combined endpoint death, re-infarction, and urgent target vessel revascularization in the prehospital-treated patients (3.0 vs. 7.0%, P?=?0.09), this difference was significant if patients were classified as treated (4/161 vs. 13/174; 2.5 vs. 7.5%, P?P?=?0.8).

Conclusions

Early inhibition of the platelet ADP-receptor with a high loading dose of 600?mg clopidogrel given in the prehospital phase in patients with STEMI scheduled for primary PCI is safe, did not increase pre-PCI patency of the infarct vessel, but was associated with a trend towards a reduction in clinical events.     

One-year clinical outcomes with abciximab in acute myocardial infarction: results of the BRAVE-3 randomized trial

Purpose

In the Bavarian Reperfusion Alternatives Evaluation (BRAVE)-3 study upstream administration of abciximab additional to 600 mg clopidogrel loading did not reduce the infarct size in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions. The aim of this study was to investigate 1-year clinical outcomes in the BRAVE-3 study patients.

Methods

A total of 800 patients with acute STEMI within 24 h from symptom onset, all treated with 600 mg of clopidogrel were randomized in a double-blind fashion to receive either abciximab (n = 401) or placebo (n = 399) in the intensive care unit before being sent to the catheterization laboratory.

Results

The main outcome of interest of the present study, the composite of death, recurrent myocardial infarction, stroke or revascularization of the infarct-related artery (IRA) at 1 year, was 23.0% (92 patients) in the abciximab versus 25.7% (102 patients) in the placebo group [relative risk (RR) = 0.90, 95% confidence interval (CI) 0.67–1.20; P = 0.46]. The combined incidence of death, recurrent myocardial infarction or stroke was 9.3% in the abciximab group versus 6.0% in the placebo group (RR = 1.55, 95% CI 0.93–2.58; P = 0.09). There was a significant reduction of the IRA revascularization with abciximab compared to placebo (16.3 vs. 22.3%, RR = 0.71, 95% CI 0.52–0.98; P = 0.04).

Conclusion

In patients with STEMI, all receiving 600 mg clopidogrel, abciximab did not improve overall clinical outcomes at 1 year after primary coronary stenting.     

Long-term follow-up after coronary stenting with the sirolimus-eluting stent in clinical practice: results from the prospective multi-center German Cypher Stent Registry

Aims

To obtain long-term follow-up data of the sirolimus-eluting coronary stent (SES) and to determine factors associated with clinical events and target vessel revascularization (TVR).

Methods and results

Between 2002 and 2005, 5,946 patients were treated with at least one SES. A follow-up after a median of 4.1?years was obtained in 5,247 patients (88.2?%). During the follow-up, death occurred in 9.2?% of patients, nonfatal myocardial infarction in 5.9?%, nonfatal stroke in 2.2?% and MACCE (death/myocardial infarction/stroke) in 16.3?%. Any TVR was performed in 20.3?%. Independent predictors of MACCE were: older age (p?p?p?p?p?=?0.0002), three-vessel disease (p?=?0.0012), reduced left ventricular function (p?=?0.0048), target vessel?=?bypass graft (p?=?0.0122), indication for treatment?=?ACS (p?=?0.0181) and PCI before implantation (p?=?0.0308). Independent predictors of TVR were target vessel?=?coronary bypass (<0.0001), two- or three-vessel disease (p?p?p?=?0.0012) and older age being a protective factor (p?=?0.0187).

Conclusions

Long-term follow-up of the SES in clinical practice showed clinical event rates that were comparable to randomized trials with a MACCE rate of 16.3?% and TVR rate of 20.3?%.     

Impact of white blood cell count on myocardial salvage,infarct size,and clinical outcomes in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a magnetic resonance imaging study

We sought to determine the relationship between white blood cell count (WBCc) and infarct size assessed by cardiovascular magnetic resonance imaging (CMR) in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). In 198 patients undergoing primary PCI for STEMI, WBCc was measured upon arrival and CMR was performed a median of 7 days after the index event. Infarct size was measured on delayed enhancement imaging and the area at risk (AAR) was quantified on T2-weighted images. Baseline characteristics were not significantly different between the high WBCc group (>11,000/mm³, n = 91) and low WBCc group (≤11,000/mm³, n = 107). The median infarct size was larger in the high WBCc group than in the low WBCc group [22.0 % (16.7–33.9) vs. 14.7 % (8.5–24.7), p < 0.01]. Compared with the low WBCc group, the high WBCc group had a greater extent of AAR and a smaller myocardial salvage index [MSI = (AAR?infarct size)/AAR × 100]. The major adverse cardiovascular events (MACE) including cardiac death, nonfatal reinfarction, and rehospitalization for congestive heart failure at 12-month occurred more frequently in the high WBCc group (12.1 vs. 0.9 %, p < 0.01). In multivariate analysis, high WBCc significantly increased the risk of a large infarct (OR 3.04 95 % CI 1.65–5.61, p < 0.01), a low MSI (OR 2.08, 95 % CI 1.13–3.86, p = 0.02), and 1-year MACE (OR 16.0, 95 % CI 1.89–134.5, p = 0.01). In patients undergoing primary PCI for STEMI, an elevated baseline WBCc is associated with less salvaged myocardium, larger infarct size and poorer clinical outcomes.     

Long-term clinical outcomes following sirolimus-eluting stent implantation in patients with acute myocardial infarction. A meta-analysis of randomized trials

Objectives

The aim of this study was to perform a meta-analysis of randomized trials, evaluating the long-term outcomes of sirolimus-eluting stents (SES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI).

Background

Despite short-term outcomes of patients with STEMI undergoing primary percutaneous coronary intervention indicate a benefit of SES in terms of reintervention, several concerns remain on the long-term safety and efficacy of SES.

Methods

A systematic literature search of electronic resources, through October 2011, was performed using specific search terms. Included trials were randomized studies comparing SES to BMS in STEMI patients, with a follow-up ≥3?years.

Results

Seven trials were included, with a total of 2,364 patients. At a median follow-up of 3?years, SES significantly reduced the risk of target-vessel revascularization when compared with BMS [odds ratio (OR), 0.44; 95?% confidence interval (CI), 0.34–0.57; p?<?0.0001], without increasing the risk of mortality (OR 0.78; 95?% CI, 0.57–1.08; p?=?0.14), reinfarction (OR 0.91; 95?% CI, 0.61–1.35, p?=?0.64) and early to late stent thrombosis (OR 0.77; 95?% CI, 0.49–1.20; p?=?0.25). However after the first year, SES did not further reduce target-vessel revascularization (OR 1.06; 95?% CI, 0.64–1.74; p?=?0.83) and increased the risk of very late stent thrombosis (OR 2.81; 95?% CI, 1.33–5.92; p?=?0.007).

Conclusions

At long-term follow-up, SES compared to BMS use in STEMI patients reduces the risk of target-vessel revascularization, without increasing the risk of death and reinfarction. However, the strong SES efficacy is counterbalanced by a significant risk of very late stent thrombosis.     

The frequency of vascular complications associated with the use of vascular closure devices varies by indication for cardiac catheterization

Objective

This study aimed at exploring access site-related vascular complication rates associated with the use of the vascular closure device (VCD) Angio-Seal? in an unselected patient population undergoing elective as well as emergency coronary angiography or intervention.

Background

The VCD Angio-Seal? is widely used to achieve hemostasis after diagnostic and interventional cardiac procedures. There are only little data on the frequency of vascular complications after the use of the VCD Angio-Seal? in patients in non-elective settings.

Method

In-hospital vascular complications were prospectively assessed in 4,653 consecutive cardiac catheterization procedures, which included 2,772 elective diagnostic and 960 elective percutaneous coronary interventions (PCI), and 921 emergency cardiac catheterizations in patients with NSTEMI/STEMI. In 2,077 procedures manual compression (MC) and in 2,576 procedures VCD was applied. Complication rates for manual compression and VCD use were studied and multivariate analyses performed to disclose predictors for access site-related vascular complications.

Results

Vascular complication rates in patients receiving MC to achieve hemostasis were similar to those receiving a VCD (MC 3.4% vs. VCD 3.2%, p?=?n.s.). Separate analysis of vascular complication rates for subgroups revealed a significant reduction in vascular complications for the PCI group using a VCD (MC 7.7% vs. VCD 3.2%, p?=?0.003). In emergencies VCD use lead to a rise in vascular complications (MC 0.9% vs. VCD 6.3%, p?<?0.001).

Conclusions

In contrast to elective settings, the risk of access site-related vascular complications is significantly increased after application of the VCD Angio-Seal? in patients undergoing emergency catheterizations for NSTEMI/STEMI compared with manual compression.     

Effects of Tirofiban Maintenance Duration on Myocardial Perfusion Defect Severity in Anterior Myocardial Infarction

Introduction

Percutaneous coronary intervention (PCI) does not often produce optimal results, despite restoration of coronary blood flow at myocardial recovery, because of impaired microvascular perfusion. This study aimed to investigate and evaluate with ^99mTc-sestamibi scan whether the results of PCI can be changed by maintenance infusion of tirofiban for 24 or 48 h in patients presenting with anterior ST-elevation myocardial infarction (STEMI).

Methods

The study included 84 patients with anterior STEMI who were candidates for primary PCI and whose occlusion was in the proximal or mid-left anterior descending artery. Patients were given 25 μg/kg/3 min tirofiban and randomized to receive maintenance infusion at 0.15 μg/kg/min for 24 or 48 h. A resting ^99mTc sestamibi scan was performed on the 5th day post-procedure before discharge. The primary efficacy endpoint was a patient’s score on a 5-point scoring system for perfusion defect severity. Major adverse cardiac events (MACE) were defined as death from any cause, re-infarction, and clinically driven target-vessel revascularization within the first 6 months.

Results

Baseline characteristics of the patients were similar in the two infusion groups (n = 42 per group). There was no significant difference in the symptom onset-to-presentation time or door-to-balloon time between the two groups. With the exception of basal anteroseptal and basal anterior segments, significant reductions were obtained on the 5-point scoring system for perfusion defect severity in segments and in the summed rest scores. No significant differences were observed between the two groups in the incidence of MACE at 6 months. The safety profile did not differ between 24 and 48 h infusions of tirofiban.

Conclusion

The use of tirofiban, when administered at a high bolus dose and maintained for 48 h, was safe and significantly reduced perfusion defect severity in patients with anterior STEMI presenting early after symptom onset and undergoing primary PCI.     

Reperfusion therapy and mortality in octogenarian STEMI patients: results from the Belgian STEMI registry

Background

Treatment strategies and outcome of ST-elevation myocardial infarction (STEMI) have been mainly studied in middle-aged patients. With increasing lifetime expectancy, the proportion of octogenarians will substantially increase. We aimed to evaluate whether the benefit of currently recommended reperfusion strategies is maintained in octogenarians.

Methods

Reperfusion therapy and in-hospital mortality were evaluated in 1,092 octogenarians and compared with 7,984 STEMI patients <80 years old based on data from the prospective Belgian STEMI registry.

Results

The octogenarian STEMI group had more cardiovascular comorbidities, contained more female patients and presented more frequently with cardiac failure (Killip class >1, 40 vs. 20 %) compared with their younger counterparts (all p < 0.05). Although the rate of thrombolysis was similar (9.2 vs. 9.9 %) between both groups, a conservative approach was chosen more frequently (13.8 vs. 4.7 %), while PCI was performed less frequently (76.9 vs. 85.4 %) in octogenarians (p < 0.001). Moreover, ischemic time and door-to-needle/balloon time were longer for octogenarians. In-hospital mortality for octogenarians was 17.8 vs. 5.5 % in the younger group [adjusted OR 2.43(1.92–3.08)]. In haemodynamically stable octogenarians, PCI seemed to improve outcome compared with thrombolysis or conservative treatment (5.7 vs. 12.7 vs. 8.5 %, p = 0.09). In octogenarians with cardiac failure, in-hospital mortality was extremely high independent of the chosen reperfusion therapy (34.6 vs. 31.6 vs. 36.3 %, p = 0.88).

Conclusions

In-hospital mortality in octogenarian STEMI patients was high and related to a high prevalence of cardiac failure. Less PCI was performed in the octogenarian group compared with the younger patients, although mortality benefit of PCI was maintained in haemodynamically stable octogenarians.     

Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial

Purpose

To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72?h continuous infusion of 0.1?μg/kg/min levosimendan or standard post-CPB inotrope infusion.

Results

Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p?=?0.35), length of mechanical ventilation (5.9?±?5 vs. 6.9?±?8?days, p?=?0.54), and pediatric cardiac intensive care unit (PCICU) stay (11?±?8 vs. 14?±?14?days, p?=?0.26). Low cardiac output syndrome occurred in 37?% of levosimendan patients and in 61?% of controls (p?=?0.059, OR 0.38, 95?% CI 0.14–1.0). Postoperative heart rate, with a significant difference at 6 (p?=?0.008), 12 (p?=?0.037), and 24?h (p?=?0.046), and lactate levels, with a significant difference at PCICU admission (p?=?0.015) and after 6?h (p?=?0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6?h and after 12?h, (p?Conclusions Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3–4 neonates.     

Effects of combined deferiprone with deferoxamine on right ventricular function in thalassaemia major

Background

Thrombus aspiration (TA) has been shown to improve microvascular perfusion during primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI). The objective of our study was to assess the relationship between TA and myocardial edema, myocardial hemorrhage, microvascular obstruction (MVO) and left ventricular remodeling in STEMI patients using cardiovascular magnetic resonance (CMR).

Methods

Sixty patients were enrolled post primary PCI and underwent CMR on a 1.5 T scanner at 48 hours and 6 months. Patients were retrospectively stratified into 2 groups: those that received TA (35 patients) versus that did not receive thrombus aspiration (NTA) (25 patients). Myocardial edema and myocardial hemorrhage were assessed by T2 and T2* quantification respectively. MVO was assessed via a contrast-enhanced T1-weighted inversion recovery gradient-echo sequence.

Results

At 48 hours, infarct segment T2 (NTA 57.9 ms vs. TA 52.1 ms, p = 0.022) was lower in the TA group. Also, infarct segment T2* was higher in the TA group (NTA 29.3 ms vs. TA 37.8 ms, p = 0.007). MVO incidence was lower in the TA group (NTA 88% vs. TA 54%, p = 0.013). At 6 months, left ventricular end-diastolic volume index (NTA 91.9 ml/m2 vs. TA 68.3 ml/m2, p = 0.013) and left ventricular end systolic volume index (NTA 52.1 ml/m2 vs. TA 32.4 ml/m2, p = 0.008) were lower and infarct segment systolic wall thickening was higher in the TA group (NTA 3.5% vs. TA 74.8%, p = 0.003).

Conclusion

TA during primary PCI is associated with reduced myocardial edema, myocardial hemorrhage, left ventricular remodeling and incidence of MVO after STEMI.     

Patterns of post-traumatic stress symptoms in families after paediatric intensive care

Purpose

To establish longitudinal rates of post-traumatic stress in a cohort of child–parent pairs; to determine associations with poorer outcome.

Method

This was a prospective longitudinal cohort study set in a 21-bed unit. In total 66 consecutive admissions aged 7–17?years were screened with one parent at 3 and 12?months post-discharge. Measures used were the Children’s Revised Impact of Event Scale (CRIES-8) and the SPAN (short form of Davidson Trauma Scale).

Results

In total 29 (44?%) child–parent pairs contained at least one member who scored above cut-off 12 months after discharge, with scores increasing over time for 18 parents and 26 children. At 3?months, 28 (42?%) parents and 20 (32?%) children scored above cut-off; at 12?months the rates were 18 (27?%) parents and 17 (26?%) children. Parents scoring above cut-off at 12?months were more likely to have had a child admitted non-electively (100?% vs. 77?%, p?=?0.028); had higher 3-month anxiety scores (11.5 vs. 4.5, p?=?0.001) and their children had higher post-traumatic stress scores at 3?months (14 vs. 8, p?=?0.017). Children who scored above cut-off at 12?months had higher 3-month post-traumatic stress scores (18 vs. 7, p?=?0.001) and higher Paediatric Index of Mortality (PIM) scores on admission (10 vs. 4, p?=?0.037).

Conclusions

The findings that (a) nearly half of families were still experiencing significant symptoms of post-traumatic stress 12?months after discharge; (b) their distress was predicted more by subjective than by objective factors and (c) many experienced delayed reactions, indicate the need for longer-term monitoring and more support for families in this situation     

Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department

Introduction

Noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) are both advocated in the treatment of cardiogenic pulmonary edema (CPE); however, the superiority of one technique over the other has not been clearly demonstrated. With regard to its physiological effects, we hypothesized that NIPSV would be better than CPAP in terms of clinical benefit.

Methods

In a prospective, randomized, controlled study performed in four emergency departments, 200 patients were assigned to CPAP (n?=?101) or NIPSV (n?=?99). Primary outcome was combined events of hospital death and tracheal intubation. Secondary outcomes included resolution time, myocardial infarction rate, and length of hospital stay. Separate analysis was performed in patients with hypercapnia and those with high B-type natriuretic peptide (>500?pg/ml).

Results

Hospital death occurred in 5 (5.0%) patients receiving NIPSV and 3 (2.9%) patients receiving CPAP (p?=?0.56). The need for intubation was observed in 6 (6%) patients in the NIPSV group and 4 (3.9%) patients in the CPAP group (p?=?0.46). Combined events were similar in both groups. NIPSV was associated to a shorter resolution time compared to CPAP (159?±?54 vs. 210?±?73?min; p?Conclusions During CPE, NIPSV accelerates the improvement of respiratory failure compared to CPAP but does not affect primary clinical outcome either in overall population or in subgroups of patients with hypercapnia or those with high B-type natriuretic peptide.     

Statin effect on thrombin inhibitor effectiveness during percutaneous coronary intervention: a post-hoc analysis from the ISAR-REACT 3 trial

Objective

To determine whether statin therapy influences the efficacy of thrombin inhibitor bivalirudin or unfractionated heparin (UFH) during PCI.

Setting and patients

The post-hoc analysis of the ISAR-REACT 3 Trial included 4,570 patients: 3,106 patients were on statin therapy and 1,464 patients were not on statin therapy at the time of PCI procedure.

Main outcome measures

The primary outcome of this analysis was the 30-day composite of death, myocardial infarction, target vessel revascularization (TVR) or major bleeding.

Results

The primary outcome occurred in 7.9% patients (n?=?246) in the statin group versus 9.8% (n?=?143) in the non-statin group (P?=?0.036). There was an interaction in univariate (P?=?0.028) and multivariable (P?=?0.026) analysis between pre-PCI statin therapy and the type of antithrombotic therapy regarding myocardial infarction. In the statin group, bivalirudin significantly reduced the incidence of major bleeding (2.6 vs. 4.3%, P?=?0.013) with no significant difference in the incidence of myocardial infarction (4.9 vs. 5.2%; P?=?0.73) compared with UFH. In the non-statin group, bivalirudin was inferior to UFH regarding the incidence of myocardial infarction (7.1 vs. 4.1%, P?=?0.013), yet major bleeding remained lower among bivalirudin-treated patients (4.0 vs. 5.2%, P?=?0.25).

Conclusion

This post-hoc analysis suggests the existence of an interaction between statin therapy before PCI and antithrombotic therapy during PCI. Patients receiving bivalirudin therapy at the time of PCI showed less periprocedural myocardial infarction when on pre-PCI statin therapy which has to be investigated in further studies.     

Renal impairment according to acute kidney injury network criteria among ST elevation myocardial infarction patients undergoing primary percutaneous intervention: a retrospective observational study

Objective

Conflicting data exists regarding the frequency and significance of acute kidney injury (AKI) in ST segment elevation MI (STEMI) patients. The acute kidney injury network (AKIN) classification has been shown to predict mortality in various critically ill patients; however, limited information is available regarding its use and its clinical relevance among STEMI patients.

Study design and methods

We retrospectively studied 1,033 STEMI patients undergoing primary percutaneous intervention (PCI). AKI was identified on the basis of the changes in serum creatinine during hospitalization according to the AKIN criteria. Patients were assessed for in-hospital adverse outcomes as well as all-cause mortality up to 5 years.

Results

Overall, 100 patients (9.6 %) developed AKI: 79 patients (79 %) had stage 1, 14 patients (14 %) developed stage 2, and 7 patients (7 %) developed stage 3 AKI. Patients with AKI had more complications during hospitalization, with higher 30 days (11 vs 1 %; p < 0.001) and 5-year all-cause mortality (29 vs 6 %; p < 0.001) compared to those without AKI. The adjusted risk of death increased proportionally to AKI severity. Compared to patients with no AKI, the adjusted hazard ratio for all-cause mortality was 6.68 (95 % confidence interval: 2.1–21.6, p = 0.002) in patients with AKI. Age, hypertension, chronic kidney injury and low left ventricular ejection fraction were independent predictors of developing AKI.

Conclusion

In STEMI patients undergoing primary PCI, AKI assessed by AKIN criteria is a frequent complication, associated with an increased risk of both short- and long-term mortality.