Renal insufficiency and vascular complications after primary angioplasty via femoral route. Impact of vascular closure devices use

Introduction and objectives

We sought to determine the incidence of vascular complications in patients with chronic kidney disease undergoing primary angioplasty via the femoral route; we also evaluated the safety and efficacy of the use of vascular closure devices in this setting.

Methods

Registry of 527 patients undergoing primary angioplasty via the femoral route from January 2003 to December 2008. Chronic kidney disease was defined as creatinine clearance less than 60 mL/min. The primary endpoint was the presence of major vascular complications.

Results

Baseline chronic kidney disease was observed in 166 (31.5%) patients. Patients with chronic kidney disease experienced higher rates of major vascular complications compared to those without worsening of renal function (8.4% vs 4.2%; P=.045), especially those requiring transfusion (6.6% vs 1.9%; P=.006). Among patients with chronic kidney disease, 129 (77.7%) received a vascular closure device and manual compression was used in 37 patients (22.3%). The risk of major vascular complications was significantly lower with vascular closure device use compared to manual compression (4.7% vs 21.6%; P=.003). Multivariable logistic regression analysis showed that the use of a vascular closure device was independently associated with a decreased risk of major vascular complications in patients with chronic kidney disease undergoing primary angioplasty (odds ratio=0.11; 95% confidence interval, 0.03-0.41; P=.001).

Conclusions

Patients with chronic kidney disease undergoing primary angioplasty via the femoral route experience higher rates of major vascular complications. The use of vascular closure devices in this group of patients is safe and is associated with lower rates of major vascular complications compared to manual compression.Full English text available from:www.revespcardiol.org     

Pulmonary hypertension in systemic lupus erythematosus: prevalence,predictors and diagnostic strategy

ObjectivesTo investigate the prevalence and predictors of pulmonary hypertension (PH) in patients with systemic lupus erythematosus (SLE) and to validate a diagnostic strategy.Methods245 patients with SLE entered a screening program. Possible PH was defined as two consecutive systolic pulmonary arterial pressure (PAP) values ≥ 40 mm Hg by echocardiography. The subsequent diagnostic procedure, including right heart catheterization if needed, confirmed or excluded the diagnosis of PH secondary to cardiopulmonary disease or SLE-related pulmonary arterial hypertension (PAH). Independent predictors of PH were identified by multivariant multiple linear or logistic regression models. The sensitivity (S), specificity (SP), positive (PPV) and negative predictive values (NPV) were calculated for different screening cutoff values.Results88% patients were women. The mean (SD) age at the time of enrolment was 45 (16) years. 12 cases of PH were detected, all secondary, with a resulting prevalence of 5%. Two consecutive echocardiographic PAP measurements ≥ 40 mm Hg performed best as the cutoff point for screening (S 100%, SP 97%, PPV 70, NPV 100), as compared with single PAP measurements ≥ 30 mm Hg or ≥ 40 mm Hg The age at the time of enrolment was the only variable independently associated with PAP values (p = 0.0001), with the SLICC damage index score showing a borderline association (p = 0.08). Only the age at the time of enrolment showed an independent association with PH (OR 1.10, 95% CI 1.06–1.17).ConclusionWe found a low prevalence of PH. Screening echocardiograms in asymptomatic lupus patients are thus not recommended. Two consecutive PAP values ≥ 40 mm Hg by echocardiogram is the best screening cutoff for starting investigations in SLE patients with suspected PH.     

Effects of Head and Neck Inclination on Bilateral Sternocleidomastoid EMG Activity in Healthy Subjects and in Patients with Myogenic Cranio-Cervical-Mandibular Dysfunction

This study was conducted in order to determine the effect of head and neck position on bilateral electromyographic (EMG) activity of the sternocleidomastoid muscles. The study was performed on 16 patients with myogenic cranio-cervical-mandibular dysfunction (CMD) and 16 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the right and left sternocleidomastoid muscles. EMG activity was recorded in the left lateral decubitus position, in a darkened room and with the individual's eyes closed, under the following experimental conditions: 1. Head, neck, and body horizontally aligned; 2. Head and neck upwardly inclined with respect to the body, simulating the effect of a thick pillow, 3. Head and neck downwardly inclined with respect to the body, simulating the effect of a thin pillow. Variation of head and neck positions was determined by measuring the distance from the angle of neck and shoulder and the apex of the shoulder (SND = shoulder—neck distance) of each individual. Then, head and neck were forward or downwardly inclined with respect to the body at one-third of SND. A significantly higher contralateral EMG activity and a more asymmetric EMG activity were observed in the CMD group than in the healthy subjects (Kruskal-Wallis Test).These results suggest a different behavior of bilateral sternocleidomastoid EMG activity in CMD patients than in healthy subjects depending on the positioning of the head and neck.     

Percutaneous alcohol septal ablation for hypertrophic obstructive cardiomyopathy: technical review and long-term clinical and echocardiographic outcomes

BackgroundPercutaneous septal ablation by alcohol-induced septal branch occlusion was introduced as a new treatment option in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Our aim was to evaluate procedural and long-term clinical and echocardiographic outcomes in patients with HOCM treated by alcohol septal ablation (ASA) at our center.MethodsThis single-center retrospective study included 14 consecutive HOCM patients undergoing percutaneous ASA (66.4 ± 12.1 years, 71.4% female). At baseline all patients presented persistent symptoms despite optimized medical treatment, left ventricular outflow tract (LVOT) obstruction with a peak gradient >50 mmHg, systolic anterior motion of the mitral valve, and ventricular septal thickness ≥15 mm. ASA was considered successful when the LVOT pressure gradient fell to less than 50% of baseline value. All patients had echocardiographic evaluation at baseline, intraprocedure and at follow-up, and a long-term clinical follow-up (25 ± 38 months) with evaluation of functional class and occurrence of symptoms or cardiovascular events.ResultsPercutaneous ASA achieved a 71.4% acute and 85.7% long-term success rate. Peak LVOT gradient decreased from 104 ± 40 mmHg at baseline to 58 ± 30 mmHg intraprocedure (p = 0.03) and 35 ± 26 mmHg at follow-up (p = 0.001); total gradient decrease was 75 ± 43 mmHg. Ventricular septal thickness and mitral regurgitation also presented significant decreases during follow-up (from 24 ± 5 mm to 18 ± 4 mm, p = 0.02, and from grade 2.4 ± 0.6 to 1.4 ± 0.5, p < 0.001, respectively). A tendency for long-term improvement in NYHA functional class (from 2.6 ± 1.1 to 1.8 ± 1.4, p = 0.09) was observed. Procedural complications occurred in 6.7% of patients; two deaths and one transient ischemic attack occurred in-hospital, but no long-term clinical events were recorded.ConclusionsPercutaneous ASA is an effective treatment for symptomatic patients with HOCM, obtaining a marked decrease in LVOT pressure gradient and symptomatic improvement. Despite the occurrence of a significant number of procedural complications, the favorable long-term outcomes underline the potential of ASA as a percutaneous alternative to surgical myectomy.     

Treatment of hairy cell leukemia: long-term results in a developing country

Twenty-nine consecutive patients with hairy cell leukemia (HCL) were treated in two institutions with interferon (IFN, n = 18) or cladribine (n = 11), between July 1987 and May 2011. Median age was 62 (range 29-83) years; there were 21 males and 8 females. Seven of the 18 patients in the IFN group (39%) achieved a complete remission (CR), whereas all the patients in the 2-CDA group entered a CR. Three patients in the 2-CDA group relapsed and needed an additional course of the drug, 2, 3 and 6 years after the initial one. The median overall survival (OS) of the whole group has not been reached, being above 217 months, the 217-month OS being 91%. The survival of patients treated with either IFN or 2-CDA was not statistically different (94% OS at 217 months versus 91% OS at 133 months, respectively). The data that we present here suggest that treatment of HCL with either 2-CDA or IFN is equally effective; treatment costs with IFN are substantially lower than those of the purine analog.