Prognostic utility of T-wave alternans in a real-world population of patients with left ventricular dysfunction: the PREVENT-SCD study

Background

The predictive value of T-wave alternans (TWA) for lethal ventricular tachyarrhythmia in patients with left ventricular (LV) dysfunction is controversial. Also, long-term arrhythmia risk of patients ineligible for the TWA test is unknown.

Methods

This was a multicenter, prospective observational study of patients with LV ejection fraction ??40% due to ischemic or non-ischemic cardiomyopathies, designed to evaluate the prognostic value of TWA for lethal ventricular tachyarrhythmia. The primary end point was a composite of sudden cardiac death, sustained rapid ventricular tachycardia (VT) or ventricular fibrillation (VF), and appropriate defibrillator therapy for rapid VT or VF.

Results

Among 453 patients enrolled in the study, 280 (62%) were eligible for the TWA test. TWA was negative in 82 patients (29%), who accounted for 18% of the total population. The median of follow-up was 36?months. The 3-year event-free rate for the primary end point was significantly higher in TWA-negative patients (97.0%) than in TWA non-negative patients (89.5%, P?=?0.037) and those ineligible for the TWA test (84.4%, P?=?0.003). Multivariable analysis identified both non-negative TWA [hazard ratio (HR) 4.43; 95% confidence interval (CI) 1.02?C19.2; P?=?0.047) and ineligibility for the TWA test (HR 6.89; 95% CI 1.59?C29.9; P?=?0.010) to be independent predictors of the primary end point.

Conclusions

TWA showed high negative predictive ability for lethal ventricular tachyarrhythmia in patients with LV dysfunction, although the TWA-negative patients accounted for only 18% of the entire population. Those ineligible for the TWA test had the highest risk for lethal ventricular tachyarrhythmia.     

Clinical significance of primary lesion FDG uptake for choice between oesophagectomy and endoscopic submucosal dissection for resectable oesophageal squamous cell carcinomas

Objectives

To correlate primary oesophageal squamous cell carcinoma (SCC) ¹⁸F-fluoro-deoxyglucose (FDG) uptake with pathological factors and examine its significance regarding choice of therapy.

Methods

We retrospectively examined the factors affecting visible and non-visible FDG uptake in 37 primary lesions in 32 oesophageal SCC patients who underwent PET/CT before oesophagectomy or endoscopic submucosal dissection (ESD). We divided the lesions into pathological depth invasion ≥sm2 oesophagectomy (n?=?18) and ≤sm1 ESD (n?=?19) indicated groups and compared the diagnostic accuracy of FDG-PET with that of endoscopic ultrasound (EUS) performed for 23 superficial lesions to discriminate between these groups.

Results

There were 17 visible and 20 non-visible lesions. The lesion visibility was significantly higher in the larger (≥40 mm), non-flat type, more deeply invaded, positive vascular invasion (P?P?=?0.04) and higher Glut-1 score (P?=?0.005) tumour groups. When the visible and non-visible lesions indicated a need for oesophagectomy and ESD respectively, the sensitivity, specificity and accuracy of oesophagectomy were 94% (17/18), 100% (19/19) and 97% (36/37) and those of EUS were 75% (3/4), 79% (15/19) and 78% (18/23) respectively.

Conclusions

Primary lesion FDG visibility can be one of the indicators for choosing between oesophagectomy and ESD for resectable oesophageal SCCs.     

Significance of percutaneous transluminal coronary intervention for chronic total occlusions assessed as non-viable by myocardial scintigraphy

OBJECTIVES: The effectiveness of percutaneous transluminal coronary intervention (PCI) was evaluated for chronic total occlusion (CTO) assessed as non-viable by myocardial scintigraphy. METHODS: In the period from January 2003 to October 2006, 17 patients who had successful reopening of the artery through revascularization by PCI for CTO assessed as non-viable were classified as the P group, and 30 patients whose course was observed while undergoing medical therapy after being assessed as nonviable formed the M group. Left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and SD/chord were measured in both groups before the procedure and at the chronic phase (mean 6.2 months). The incidences of chronic cardiac events at mean 20.5 months were compared. RESULTS: No significant differences were revealed between the two groups in LVEF and LVEDV prior to the procedure. No significant differences between the groups were revealed for Delta LVEF or Delta LVEDV. A significant improvement (p < 0.05) was revealed for SD/chord in the P group with - 1.50 +/- 0.25 before the procedure, becoming - 1.34 +/- 0.33 in the chronic phase, but the M group revealed no significant change. No significant difference was revealed in the avoidance of chronic cardiac events with 94.1% for the P group and 86.0% for the M group. CONCLUSIONS: Improvement in local left ventricular wall motion by revascularization is possible even in patients with chronic total occlusions assessed as non-viable by myocardium scintigraphy.     

Edaravone preserves coronary microvascular endothelial function after ischemia/reperfusion on the beating canine heart in vivo

We examined whether edaravone (3-methyl-1-phenyl-2-pyrazolin-5-one), a free radical scavenger, exerts its protective effect on coronary microvessels after ischemia/reperfusion (I/R) in vivo. Ninety-minute coronary occlusion followed by reperfusion was performed in 16 open-chest dogs with and without edaravone administration. Coronary small artery (> or = 100 microm in size) and arteriolar (< 100 microm) vasodilation, in the presence of endothelium-dependent (acetylcholine) or -independent (papaverine) vasodilators, was directly observed using intravital microscopy before and after I/R. I/R impaired microvascular vasodilation in response to acetylcholine, whereas administration of edaravone preserved the response in microvessels of both sizes, but to a greater extent in the coronary small arteries. No significant changes were noted with papaverine administration. In the edaravone group, the fluorescent intensity from reactive oxygen species (ROS) was lower, whereas nitric oxide (NO) intensity was higher relative to controls in the microvessels of the ischemic area. In conclusion, edaravone preserves coronary microvascular endothelial function after I/R in vivo. These effects, which were NO-mediated, were attributed to the ROS scavenging properties of edaravone.     

Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check?

We experienced an accident related to insufficient checking of the anesthesia machine. The anesthesiologist could not ventilate manually after starting anesthesia. The cause of this case was a simple mistake of not moving the switch from ventilator to bag, but he thought severe asthma attack had occurred with the patient. About 10 minutes was lost before he recognized the real cause and the patient suffered severe hypoxia. After this event we conducted a survey of "Do you really check the anesthesia machine before anesthesia using J.S.A. checklist?" on our seven anesthesiologists. Leak test was carried out almost perfectly but other test was not. Therefore we put anesthesiologists under an obligation to use the check sheet before anesthesia and file the sheet in the medical record. The safety management of anesthesia is not only to take the safety measures but also to check the actual conditions.     

Changes of asymmetric dimethylarginine, nitric oxide, tetrahydrobiopterin, and oxidative stress in patients with acute myocardial infarction by medical treatments

The relationship among the nitric oxide synthase (NOS) inhibitor [asymmetric dimethylarginine (ADMA)], NOS cofactor [tetrahydrobiopterin (BH(4))], and superoxide anion in the patients with acute myocardial infarction (AMI) is still unknown. This study sought to assess the NOS inhibitor and cofactor with oxidative stress in AMI patients (n=9) during initial administration and 4 weeks after medical treatments. We measured plasma NOS inhibitor and cofactor (ADMA and BH(4)) by HPLC and plasma oxidized-LDL by ELISA. Blood samples from age-matched healthy volunteers (n=9) were taken for comparison. In AMI, plasma ADMA, oxidized-BH(4) (BH(2)+biopterin) and oxidized-LDL significantly increased (P<0.0001, P<0.01 and P<0.05 vs. healthy volunteers) and plasma BH(4), plasma nitrate and L-arginine/ADMA significantly decreased compared with healthy volunteers (P<0.0001, P<0.05 and P<0.005 vs. healthy volunteers). Medical treatments improved plasma ADMA, nitrate, BH(4) and oxidized-LDL. In conclusion, ADMA increased, and NO and BH(4) decreased with oxidative stress in AMI, and these mediators improved in AMI patients with medical treatments. These findings indicated that inhibition of NOS with oxidative stress plays a crucial role in endothelial dysfunction in patients with AMI.