Percutaneous Myocardial Laser Revascularization

Transmyocardial laser revascularization (TMR) is an experimental procedure for intractable angina that has demonstrated clinical benefit. The majority of patients who had TMR have significant reduction of angina. TMR has been performed exclusively by thoracic and cardiac surgeons using a handhold CO₂ laser device. The development of a prototype percutaneous device that delivers mid-infrared laser energy (Ho:YAG) through a 9Fr coaxial catheter system recently has been reported. The long-term benefits of this percutaneous approach is being defined in the context of the randomized PACIFIC Trial. The initial follow-up suggested significant relief of angina in the majority of treated patients, and the results are likely to be equal or similar to those of surgical TMR. The safety data of percutaneous myocardial revascularization (PMR) with the CardioGenesis system showed exceedingly low morbidity and mortality.     

Endobronchial foreign bodies in Vietnamese adults are related to eating habits

Background and objective: A high percentage of bronchoscopically extracted foreign bodies in Ho Chi Minh City were pits of the sapote fruit, a finding previously unreported. This paper presents a review of foreign body extractions, which identifies the substances found, documents the diagnostic pathway and draws attention to the specific aspiration risk of the sapote pit. Methods: The records of 100 consecutive adults who were found to have a bronchial foreign body during flexible bronchoscopy were reviewed. Results: In 83% of patients, the foreign body extraction was performed more than 2 weeks after the aspiration had occurred. In only 34% of patients was the diagnosis of an aspirated foreign body considered early in the patient's clinical course. The most frequent foreign bodies found were sapote pits (41%), followed by small bones (38%). Foreign bodies were lodged more frequently in the right bronchial tree (64%). In 98% of patients, the foreign bodies were successfully removed with the flexible scope. There was one postoperative death, which was not ascribed to the procedure. Conclusions: Physicians need to consider foreign body aspirations when evaluating patients with recurrent pneumonia, unexplained cough or atelectasis. Awareness of this problem might lead to public health measures that could reduce the incidence of these aspirations.     

Bone pain from granulocyte colony stimulating factor: does clinical trial sponsorship by a pharmaceutical company influence its reporting?

ALDAIRY Y., NGUYEN P.L. & JATOI A. (2011) European Journal of Cancer Care 20 , 72–76
Bone pain from granulocyte colony stimulating factor: does clinical trial sponsorship by a pharmaceutical company influence its reporting? It is alleged that pharmaceutical companies sometimes unfairly present clinical trial results. To our knowledge, studies have not explored whether such alleged unfair reporting also occurs in the testing of palliative care agents in cancer patients, a particularly vulnerable group. Therefore, a systematic search was conducted to retrieve all published, prospective clinical trials that used granulocyte colony stimulating factor starting in 2003. Because granulocyte colony stimulating factor can cause severe bone pain – a concerning but historically under‐reported symptom in cancer patients – this symptom was assessed to determine whether differences in reporting occurred based on pharmaceutical company‐sponsorship. A total of 239 published clinical trials met the present study's eligibility criteria and were retrievable. Within this entire group of studies, 65 (27%) were pharmaceutical company‐sponsored, and only 31 (13%) reported on bone pain. However, pharmaceutical company‐sponsored trials reported on bone pain at a higher rate compared with other studies: 23% versus 9% (P= 0.005), and this conclusion did not change after adjusting for dose, use of the slow release formulation and year of publication. The reporting of adverse events from cancer symptom control and palliative care interventions should be improved – especially in trials not sponsored by pharmaceutical companies.     

True Incidence of Pacemaker Syndrome

HELDMAN, D., ET AL.: True Incidence of Pacemaker Syndrome. Although the purported incidence of pacemaker syndrome according to the literature is only 5%–15%, this is based on a series of patients with VVI pacing. Increasing numbers of studies are being reported in which patients prefer the dual chamber mode despite little benefit being demonstrated on objective testing, suggesting that pacemaker syndrome may be more common than is generally reported. This study was designed to evaluate the reported symptoms in a series of patients programmed to both the VVI and one or more dual chamber modes. Forty unselected patients with dual chamber pacemakers were entered into a blind, randomized trial comparing the symptoms associated with VVI pacing to those associated with dual chamber pacing. Patients were randomized to either WI or dual chamber pacing. At the end of 1 week, questionnaires rating 16 different symptoms were completed. Blood pressure, LV function, presence of ventriculoatrial conduction, and ability to override the pacemaker were evaluated. The pacemaker was then programmed to the other mode. Overall, 12 of 16 symptoms were significantly worse in the VVI as compared to dual chamber mode. The most highly significant (p < 0.005) were shortness of breath, dizziness, fatigue, pulsations in the neck or abdomen, cough, and apprehension. Pacemaker syndrome was clinically recognized in 83% of patients paced in the WI mode with 65% of patients experiencing moderate to severe symptoms. There were no readily identified clinical, hemodynamic, or electrophysiological parameters that predicted which patients would develop pacemaker syndrome. Thus, when patients have an opportunity to experience both pacing modes in close proximity to one another, there is a high incidence of pacemaker syndrome in the VVI mode.     

Left Atrial Appendage Studied by Computed Tomography to Help Planning for Appendage Closure Device Placement

Left Atrial Appendage Studied by Computed Tomography . Objective: To quantitatively study various morphologic parameters of the left atrial appendage (LAA) by computed tomography (CT) to aid the preoperative planning and implantation of left atrial appendage closure devices. Methods: In 612 cases of patients with or without atrial fibrillation (AF), a cardiac CT study was performed. Results: The classification of general LAA morphology included ChickenWing type (18.3%), WindSock (46.7%), Cauliflower type (29.1%), and Cactus type (5.9%). Anatomical relationship of the LAA to the left superior pulmonary vein (LSPV) were classified as high type (superior to LSPV, 30.2%), mid type (parallel to LSPV, 58.1%), and low type (inferior to LSPV, 11.7%). LAA ostium could be classified into 5 types including oval (68.9%), foot‐like (10%), triangular (7.7%), water drop‐like (7.7%), and round (5.7%). Two‐dimensional (2D) orthogonal method was obviously not accurate for determining the LAA orifice because the measurement was often unparallel to the LAA orifice. Two‐dimensional oblique method was better than 3‐dimensional method in reproducibility to determine the size of LAA ostium. The diameter calculated from the perimeter of the LAA ostium was superior to the diameter from direct measurement of the LAA ostium for selecting the occluder. Conclusion: The morphology of the LAA and the LA ostium are extremely complex and heterogeneous. Sixty‐four‐channel cardiac CT could assist preoperative planning of LAA closure device placement. The diameter of the LAA ostium calculated from the perimeter is the best parameter for sizing the LAA occluder. (J Cardiovasc Electrophysiol, Vol. 21, pp. 973‐982, September 2010)     

Gender Differences in the Clinical Characteristics and Atrioventricular Nodal Conduction Properties in Patients With Atrioventricular Nodal Reentrant Tachycardia

Gender Differences in Patients With AVNRT. Introduction: The detailed electrophysiological characteristics of the gender differences associated with atrioventricular nodal reentrant tachycardia (AVNRT) have not been clarified. This study investigated the gender‐related electrophysiological differences in a large series of patients undergoing radiofrequency catheter ablation. Methods and Results: A total of 2,088 consecutive AVNRT patients (men/women 869/1,219) who underwent catheter ablation were enrolled in this study. We evaluated the gender differences in their electrophysiological characteristics. Women had a significantly younger age of onset, higher incidence of multiple jumps, shorter AH interval, atrial effective refractory period (ERP), anterograde fast pathway ERP, anterograde slow pathway ERP, and retrograde slow pathway ERP, and longer ventricular ERP than men. The incidence of baseline ventriculoatrial dissociation was lower in women than in men. Women needed less isoproterenol/atropine to induce AVNRT. No gender differences in the radiation exposure time, procedure time, complication rate, acute success rate, or second procedure rate were noted. Both typical and atypical AVNRT were more predominant in women. In the patients with atypical AVNRT, there was no significant gender difference in incidence of baseline ventriculoatrial dissociation; however, the retrograde slow pathway ERP was significantly shorter in women than in men. Women of premenopausal age (≤50 years old) had a significantly higher incidence of anterograde multiple jumps and a retrograde jump phenomenon, and a shorter anterograde slow pathway ERP and retrograde slow pathway ERP than those of women over 50 years old. Conclusion: Gender differences in the anterograde and retrograde AV nodal electrophysiology were noted in the patients with AVNRT. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1114‐1119)     

Contradictory Shear Stress Distribution Prevents Restenosis after Provisional Stenting for Bifurcation Lesions

Background: Endothelial shear stress is one of the local hemodynamic factors suspected in the development of coronary atherosclerosis in bifurcation lesions. In patients with provisional stenting, the endothelial shear stress (SS) distribution is unknown. Objective: The aim of this study was to investigate the magnitude and distribution of the SS of coronary bifurcation lesions stenting by the provisional approach. Methods: Ten consecutive patients were included in this study. Quantitative coronary analysis, flow study, and three‐dimensional computational analysis with the aid of the commercial software CD STAR‐CCM+ were done before and after the provisional stenting procedure and also 8 months later. Results: Clinical and angiographic follow‐up were available in all patients. No patient had a side branch (SB) stent. At the 8‐month follow‐up, no major adverse cardiac event (MACE) occurred. There was also no clinical and angiographic restenosis. Before PCI, the distal main vessel (MV)‐lateral, and the SB‐lateral subsegments had relative nonsignificant lower SS value (4.08 ± 2.78 Pa and 4.35 ± 5.04 Pa, respectively) when compared to other segments. After 8‐month follow‐up, sustained decreased SS value was shown in the distal MV‐lateral segment (4.08 ± 2.78–1.68 ± 1.65 Pa), when compared with significantly increased SS value in the SB‐lateral subsegment 4.35 ± 5.04–16.50 ± 40.45 Pa). The explanation is that after stenting in the MV, the flow was redistributed immediately after percutaneous coronary intervention (PCI) and reversed back to its original 8 months later. However, the growth of the fibrous tissue causing in‐stent restenosis (ISR) is prohibited by sirolimus on the stent struts. In contrast, in a branch opened up by plain old balloon angioplasty (POBA), the flow did not change much, the flow could even be worse because it is shifted to the MV after the cross‐sectional area of the MV improved by stenting. However, thanks to POBA, there is increased fibrous tissue formation, enough to increase the SS and prevent further accumulation of cell and cholesterol needed for more restenosis. Conclusion: In the provisional approach, low endothelial SS correlated with no restenosis for patients who underwent stenting of the MV, while a contradictory combination of high SS and no restenosis was seen in the SB after only POBA. The mechanism of prevention of restenosis in the SB is by increasing the SS while in the MV, the mechanism of prevention of ISR is secondary to sirolimus on the stents struts. (J Interven Cardiol 2010;23:319–329)