Value of coronary blood flow pattern as a predictor of functional recovery and short-term left ventricular remodeling after primary coronary angioplasty. A transthoracic Doppler study

INTRODUCTION AND OBJECTIVES: Coronary blood flow measurement using a Doppler guidewire is the most sensitive way of detecting the no-reflow phenomenon following reperfusion of a myocardial infarction (MI). New high-frequency Doppler probes enable coronary blood flow velocity to be measured noninvasively. Our aims were to study the different patterns of left anterior coronary artery blood flow observed by transthoracic Doppler echocardiography, and to describe their association with functional recovery following reperfusion of an anterior MI. METHODS: The study included 57 patients with a mean age of 60 years (range 30-85 years). An abnormal coronary blo:d flow pattern was defined as one in which there was a high peak diastolic velocity and a short deceleration time (i.e., < or = 500 ms). We compared the regional contractility, ventricular volumes, and left ventricular ejection fraction (LVEF) measured after 72 hours with those measured 1 month after MI. RESULTS: Overall, 31 patients (54%) had a normal coronary blood flow pattern (Group 1) and 26 (46%), an abnormal pattern (Group 2). After one month, regional contractility improved in Group-1 patients, as did LVEF, from 46.8 (8.6) to 52.6 (8.8)% (P=.002). In these patients, left ventricular volumes were unchanged. In contrast, regional contractility and LVEF remained unchanged in Group-2 patients whereas ventricular volumes increased, from 55.8 (12.9) to 62.9 (16.8) ml/m2 (P=.05), and from 32.2 (9.5) to 37.1 (14.9) ml/m2 (P< .05). Coronary blood flow pattern was the most important independent predictor of left ventricular remodeling, odds ratio =6.14 (95% CI, 1.56-24.17). CONCLUSIONS: Transthoracic Doppler echocardiographic assessment of coronary blood flow following reperfusion of an anterior myocardial infarction can be used to identify patients with microvascular damage who are progressing towards ventricular dilatation without recovery of myocardial function.     

Life-saving Percutaneous Mitral Valvuloplasty on a Pregnant Woman with Refractory Cardiogenic Shock

Pregnancy increases body blood volume and cardiac output. These changes can exacerbate mitral stenosis symptoms. Symptomatic mitral stenosis during pregnancy has been successfully treated with percutaneous mitral valvuloplasty (PMV). We present the case of a 35-year-old white female who developed cardiogenic shock due to severe mitral stenosis at the 22nd week of gestation and it was successfully treated with emergent PMV. This case illustrates the ability of PMV to be life-saving in such extreme conditions.     

The metabolic syndrome (MS) in the elderly: considerations on the diagnostic criteria of the International Diabetes Federation (IDF) and some proposed modifications

This study aimed at verifying the International Diabetes Federation (IDF)-indicated criteria in the elderly, characterized by a decrease of several normal values, the neglected evaluation of those values with aging, and an eventual decision of an obligatory consideration of the visceral obesity as a sign of the metabolic syndrome (MS), the relative prevalence of Acute Myocardial Infarction (AMI) and stroke. The study involved 3038 elderly persons (65-84 years), covered by the Italian Longitudinal Study on Aging (ILSA): they were investigated for the diagnosis of MS, for the prevalence of AMI and stroke at the baseline, and after 3 years. We applied both the IDF-criteria and a new concept considering the age-dependent increase of several parameters in older subjects, the previous cardio-cerebrovascular complications, as well as the presence of other diseases being independent of those complications. The prevalence of AMI and stroke determined according to the IDF-criteria is not different significantly from the results obtained in either the elderly population with "normal" or increased waist circumference (WC), nor in subjects with MS or without MS. After a 3-year-follow-up quite similar results were found. From these results one can conclude that the diagnostic criteria of the IDF for the MS are not valid for the elderly population. We propose some criteria on the basis of which one can reveal systematically significant differences between the MS and the cardiovascular complications. Our conclusion is that it seems to be necessary to verify the validity of our proposed criteria on wider long-term epidemiological studies.     

Treatment of right heart thromboemboli: the need of a randomized multicentre trial

Currently, there are not solid evidence-based recommendations on the treatment of in-transit right heart thromboemboli. We present a case of acute pulmonary embolism with right ventricular entrapped thrombus detected by echocardiography. Surgical thrombectomy was successfully carried out. Treatment options are discussed and the need of a randomized trial is stressed.     

Treatment of enterocutaneous fistula in Crohn’s Disease with adipose-derived stem cells: a comparison of protocols with and without cell expansion

Background  Expanded adipose-derived stem cells (ASC) have been shown to be effective in treating Crohn’s patients with enterocutaneous fistulas. It is possible that unexpanded cells corresponding to the stromal vascular fraction (SVF) may also be effective. Materials and methods  A subpopulation of patients from a previous proof-of-concept phase I study with enterocutaneous fistulas received autologous expanded ASCs. The same selection criteria for inclusion were applied to patients who underwent SVF implantation to treat enterocutaneous fistulas. After tract curettage, cell suspensions (either SVF cells from lipoaspirate or expanded ASCs) were injected into the tract walls, and the fistulous tract was sealed with fibrin adhesive (with or without cells). Results  In the series that received ASCs, four fistulas could be evaluated, and cure was achieved in three out of four cases. In the series that received SVF cells, four fistulas were evaluated, with cure achieved in one out of four cases. Conclusions  Although a comparison of case series cannot be considered firm evidence, a therapeutic protocol that uses expansion prior to implantation does seem to be more effective than one that uses SVF cells directly from a lipoaspirate sample.     

A study of the possibility of curing Graves' disease based on the desired reduction of thyroid mass (volume) as a consequence of 131I therapy: a speculative paper

PURPOSE: The possibility of predicting the final volume of Graves' disease thyroids submitted to 131I therapy could allow the physician to decide what activity to administer based on the desired volume reduction instead of on a fixed value of the thyroid radiation absorbed dose. In this paper the relationship between maximum uptake of 131I, fractional reduction of thyroid volume and outcome of Graves' disease is discussed. METHODS: The results are based on ultrasonography thyroid volume measurements before administration of therapy and at the moment of recovery from Graves' disease (thyroid stimulating hormone >0.3 microIU x ml(-1) in the absence of anti-thyroid drug therapy) and on measurements of 131I uptake in 40 patients. It is shown that the possibility of curing Graves' disease may be individually related to the final volume of the patient's thyroid. An equation is presented to calculate the 'optimal' final thyroid volume. RESULTS: A comparison between the traditional method, based on absorbed dose, and the final method, based on volume, has been carried out retrospectively. In the first case a median activity of 529 MBq has been administered; in the second, a median activity of 394 MBq (non-parametric Wilcoxon test, P<0.05) should be administered. The corresponding thyroid median absorbed doses are, respectively, 353 Gy and 320 Gy (non-parametric Wilcoxon test, P<0.02). CONCLUSION: A method to evaluate individually the 'optimal' final thyroid mass is presented and discussed. The method based on 'volume reduction' could probably reduce the activity and the thyroid absorbed dose compared to the method based on 'empirical' calculations, thus allowing the administration of 131I therapy to be optimized.     

Ultrasound Guidance Versus Electrical Stimulation for Femoral Perineural Catheter Insertion

Objective. Continuous femoral nerve blocks provide potent analgesia and other benefits after knee surgery. Perineural catheter placement techniques using ultrasound guidance and electrical stimulation (ES) have been described, but the optimal method remains undetermined. We tested the hypothesis that ultrasound guidance alone requires less time for femoral perineural catheter insertion and produces equivalent results compared with ES alone. Methods. Preoperatively, patients receiving a femoral perineural catheter for knee surgery were randomly assigned to either ultrasound guidance with a nonstimulating catheter or ES with a stimulating catheter. The primary outcome was the catheter placement procedure time (minutes) starting when the ultrasound transducer (ultrasound group) or catheter insertion needle (ES group) first touched the patient and ending when the catheter insertion needle was removed after catheter insertion. Results. Perineural catheters placed with ultrasound guidance (n = 20) took a median (10th–90th percentiles) of 5.0 (3.9–10.0) minutes compared with 8.5 (4.8–30.0) minutes for ES (n = 20; P = .012). All ultrasound‐guided catheters were placed according to the protocol (n = 20) versus 85% of ES‐guided catheters (n = 20; P = .086). Patients in the ultrasound group had a median procedure‐related discomfort score of 0.5 (0.0–3.1) compared with 2.5 (0.0–7.6) for the ES group (P = .015). There were no vascular punctures with ultrasound guidance versus 4 in the ES group (P = .039). Conclusions. Placement of femoral perineural catheters takes less time with ultrasound guidance compared with ES. In addition, ultrasound guidance produces less procedure‐related pain and prevents inadvertent vascular puncture.