Early Conduction Disorders Following Percutaneous Aortic Valve Replacement

Background: Percutaneous aortic valve replacement (PAVR) may be an alternative therapy for patients with severe aortic stenosis who are denied valve surgery because of age and comorbidity. Data are few regarding the incidence of early conduction disorders (CD) after PAVR. We examined the incidence and characteristics of CD in the immediate postoperative period after PAVR, and the need for permanent pacemaker (PPM) implantation.
Methods and Results: Between June 2007 and June 2008 30 patients (mean age = 82.1 ± 8.5 years) underwent PAVR in our institution. The incidence of new, postoperative CD, diagnosed by 12-lead or 24-hour Holter electrocardiogram, was 68.0%. Left bundle branch block was the most common conduction abnormality, with an incidence of 45.8%. The incidence of complete atrioventricular block requiring PPM implantation was 20%.
Conclusions: We observed a higher incidence of early conduction disorders and need for PPM implantation after PAVR than generally reported after surgery. Whether this observation is clinically important requires larger prospective studies and follow up.     

Measurement of peak inhalation rates with an In-Check Meterto identify an elderly patient's ability to use a Turbuhaler

Dry powder inhalers are designed with resistance to airflow so that a respirable cloud of particles is generated during inhalation. Some of these devices require a certain inhalation rate to produce a consistent dose of respirable particles. The aim of the study was to determine the inhalation rate of elderly patients with chronic obstructive pulmonary disease (COPD) when they inhale through a Turbuhaler and assess the potential of the In-Check Meter to identify inhalation rates. Their peak inhalation rate using a normal inhalation, pre- and post-counselling, was measured using a Turbuhaler Trainer and an In-Check Meter. Spirometry was also measured. Seventy-four COPD patients with a mean (SD) age of 79.7 (8.4) years and forced expiratory volume in 1 sec (FEV1) 41.9 (12.8)% predicted. Pre-counselling 14 obtained a rate of <30 l min(-1) with the Turbuhaler Trainer, 31 from 30 to 40 min(-1), 23 between 40-60 l min(-1) and 6 > 60 l min(-1). The median (range) peak inhalation rates with the In-Check Meter were 50 (50-70), 70 (50-130), 100 (60-200) and 225 (200-250) l min(-1). Post-counselling 7, 16,41 and 10 achieved the respective peak inhalation rates using the Turbuhaler Trainer Similarly the In-Check inhalation rates were 50 (50-60), 70 (50-130), 90 (60-200) and 250 (200-270) l min(-1). The results highlight the potential of the In-Check Meter to identify patients' inhalation rates through dry powder inhalers.     

Ultra High‐Density Multipolar Mapping With Double Ventricular Access: A Novel Technique for Ablation of Ventricular Tachycardia

Ultra High‐Density Multipolar Mapping With Double Ventricular Access . Background: Analogous to the use of circular loop catheters to guide ablation around the pulmonary veins, it may be advantageous to use a multipolar catheter in the ventricle for rapid mapping and to guide ablation. We describe a technique using double access into the left ventricle for multipolar electroanatomic mapping and ablation of scar‐mediated ventricular tachycardia (VT). Methods: Double access into the left ventricle was obtained via transseptal technique. Endocardial mapping was performed via the first transseptal sheath using a steerable duodecapolar catheter. Higher density mapping was performed in areas of dense scar (<0.5 mV) and border zone (0.5–1.5 mV). All late potentials (LPs) observed on the 20 poles were tagged and pacemapping was performed at these sites for comparison with the clinical or induced VT 12‐lead template. If VT was hemodynamically tolerated, entrainment mapping was attempted at sites demonstrating diastolic activity. Ablation was performed through the second transseptal sheath with an open‐irrigated catheter at target sites identified by LPs, pacemapping, and/or entrainment on the duodecapolar catheter. Results: Seventeen patients (88% ischemic cardiomyopathy) underwent electroanatomic mapping and ablation with double transseptal access. The mean number of endocardial mapping points was 819 ± 357 with an average mapping time of 31 ± 7 minutes. The mean number of VTs induced was 2.8 ± 1.6, mean cycle length 418 ms ± 101. LPs were seen in all patients during endocardial mapping with the duodecapolar catheter. Good (56%) and perfect (44%) pacemaps were seen in all patients when performed. Concealed entrainment, guided by the earliest diastolic activity seen on the duodecapolar catheter, was demonstrated in 4 patients (24%). Acute success was achieved in 94% of patients with complete success in 47% and partial success in 47%. The intermediate success rate (free of VT recurrence) was 69%, with an average follow‐up of 8 ± 3 months. Conclusion: Mapping and ablation of scar‐mediated VT using a multipolar catheter results in ultra high‐density delineation of the left ventricular substrate. A novel double ventricular access strategy has the potential to facilitate identification of LPs, pacemapping, and entrainment mapping. (J Cardiovasc Electrophysiol, Vol. 22, pp. 49‐56, January 2011)     

EFFECT OF SHORT COURSE OF 1,25-DIHYDROXYVITAMIN D3ON BIOCHEMICAL MARKERS OF BONE REMODELLING IN POSTMENOPAUSAL WOMEN

This study was designed to test the hypothesis that a short treatment course of 1,25(OH)₂D₃elicits a stimulation of osteoblast activity without any action on the osteoclast. To test this, oral daily doses of 0.5μg or 1μg of 1,25(OH)₂D₃were administered for 7 days to two groups (n=5 andn=7, respectively) of postmenopausal women with low bone mineral density. Markers of osteoblast activity, i.e. osteocalcin (BGP), total alkaline phosphatase activity (ALP) and bone alkaline phosphatase activity (BALP), and markers of osteoclast activity, i.e. hydroxylysyl-pyridinoline (Pyr), lysyl-pyridoline (D-Pyr), and galactosyl-hydroxylysine (GHyl) were measured in plasma and in fasting urinary samples, respectively, at sequential times during and after 1,25(OH)₂D₃administration. It resulted that short term 1μg 1,25(OH)₂D₃oral administration induced a significant (P<0.05) rise of BGP serum level without any associated increase ofD-Pyr and GHyl, the latter also expressed as GHyl to GGHyl ratio. Urinary Pyr increased significantly after 1μg daily doses of 1,25(OH)₂D₃. Thus, a short course of 1μg daily doses of 1,25(OH)₂D₃elicits a stimulation of osteoblast activity without any enhancement ofD-Pyr, the most specific marker of osteoclast activity. The enhancement of Pyr after 1μg daily doses of 1,25(OH)₂D₃might be due to the activation of extraosseous metabolic pathways rather than to the activation of osteoclast.     

Effectiveness of MitraClip Therapy in Patients with Refractory Heart Failure

Objectives

To assess outcomes for MitraClip therapy in patients with refractory heart failure (HF) and mitral regurgitation (MR) ≥3+.

Background

The beneficial role of Mitraclip also in patients with severe HF has been reported.

Methods

Out of 45 patients undergoing MitraClip implantation at our institute, 16 were on refractory HF defined as diuretics and/or inotropics infusion and/or IABP dependence (group A) or labile haemodynamic balance (group B).

Results

Patients were aged 69 ± 13 years and 75% were males. Group A (8 patients) had a mean hospitalization length before MitraClip procedure of 5333 days. Group B (8 patients) had a mean rate of hospitalization, in the last 50 days before procedure, of 254 days. Acute procedural success was observed in 94% of patients. All but one patients of group A were quickly weaned from pharmacologic and/or mechanical supports within 5 ± 3 days from procedure and discharged at 20±10 days. All patients of group B were discharged after 10±8 days from MitraClip. At 1 year: a) cumulative survival rate was 78%; b) all patients were in NYHA functional class ≤ II; c) residual MR ≤ 2 was observed in 90%; d) systolic pulmonary arterial pressure was significantly reduced compared to the baseline (from 5410 to 398; p = 0,008); e) significant reduction of cumulative HF hospitalization days in the post‐procedure year (10 days) compared to the pre‐implantation year (280 days; p = 0.023) was observed.

Conclusions

In patients with refractory HF and MR ≥3+, MitraClip implantation resulted in acute and persistent clinical benefit and net reduction of HF re‐hospitalization. (J Interven Cardiol 2015;28:61–68)

     

Effectiveness of intraaortic balloon counterpulsation in the elderly

The effectiveness of intraaortic balloon counterpulsation (IABP)in the elderly was evaluated in a group of 63 patients withacute myocardial infarction (AMI) complicated by refractoryleft ventricular failure (LVF, n = 16), cardiogenic shock (CS,n = 32) or acute ventricular septal defect (VSD, n = 15). Themean age was 61 years (range: 32–78 years); 35 patientswere under and 28 over the age of 65. Failures of insertion of the IABP catheter were significantlymore frequent in the elderly (37.5 v. 11.4%, P <0.05). The rate of major complications, which was 12.7% in the wholeseries, did not significantly differ between the two age groups. Patients with medical indications for IABP (LVF, CS) had anoverall in-hospital mortality of 68.8%: no difference was observedbetween young (67.7%) and elderly (70.6%) patients. In elderlypatients with VSD, IABP was ineffective even when reparativesurgery could be performed. Haemodynamic effects of IABP were evaluated in 32 medical patientswho survived the 4th hour of treatment. All haemodynamic parametersimproved in the early phase of pumping (within 4h) except cardiacindex and total systemic resistance, which were significantlymodified after 12 and 24 h of treatment, respectively. An earlyimprovement in stroke index proved to be predictive of survival.No haemodynamic difference was found between the age groupseither in the early or in the late phase of cardiocirculatorymechanical assistance. Fifteen patients (10 CS, 3 LVF, 2 VSD) were discharged fromthe hospital and 14 were long-term survivors (more than 60 days). It was concluded that age cannot be considered as a contraindicationto IABP during complicated AMI, since the only difference betweenthe two age groups consisted in a higher rate of failure inintroducing the catheter in the elderly.     

Interaction of Hemoglobin Lepore with Sickle Cell Trait and Microcythemia (Thalassemia) in a Southern Italian Family

An abnormal hemoglobin has been observed in a southern Italian familytogether with sickle cell hemoglobin and thalassemia (microcythemia). Thehematologic study has shown that all the carriers of the abnormal hemoglobinare microcythemic. The hemoglobins of these individuals have been studiedby paper, starch gel, starch block and agar gel electrophoresis. The abnormalhemoglobin has been isolated and identified by fingerprinting as HbLepore_Boston. The combination of Hb Lepore_Boston with thalassemia and sicklecell trait has been observed in members of this family. The hematologic andbiochemical implications of the Hb Lepore/thalassemia disease are discussed.

Submitted on March 23, 1964 Accepted on July 2, 1964