Cardiac catheterisation in nonagenarians: Single center experience

Objective To explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization. Methods We retrospectively studied 32 patients ≥ 90 years (93.0 ± 1.2 years) who underwent cardiac catheterisation in a tertiary specialist hospital (0.2% of 14,892 procedures during three years). The results were compared to a patient cohort younger than 90 years of age. Results Baseline characteristics revealed a higher prevalence of diabetes (P < 0.001), chronic obstructive pulmonary disease (P < 0.04), previous myocardial infarction (P < 0.02), and complex coronary anatomy (SYNTAX score 33 vs. 19) in nonagenarians. Patients < 90 years of age showed more hyperlipidemia (P < 0.01) and previous percutaneous coronary interventions (P < 0.015). Nonagenarians underwent coronary angiography more often for acute coronary syndrome (ACS) (P < 0.003), were presented more often in cardiogenic shock (P < 0.003), and were transferred faster to coronary angiography in cases of ACS (P < 0.0001). The observed in-hospital mortality rate (13% study group vs. 1% control group; P < 0.003) in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction (TIMI) and global registry of acute cardiac events (GRACE) mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities. Conclusions Despite the common scepticism that cardiac catheterisation exposes patients ≥ 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.     

Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery

PURPOSE: To compare the quality of pain relief and incidence of side effects between 24-hr postoperative continuous epidural infusion (CEI) and subsequent patient-controlled epidural analgesia (PCEA) with different analgesics after major abdominal surgery. METHODS: Twenty-eight women undergoing extended gynecological tumour surgery received postoperative CEI with 0.15 mL x kg(-1) x hr(-1) 0.2% ropivacaine (R: n = 14) or 0.125% bupivacaine plus 0.5 micro g x mL(-1) sufentanil (BS: n = 14) during 24 postoperative hours. Twenty-four hours later, postoperative pain management was switched to PCEA without background infusion and 5 mL single bolus application of R or BS every 20 min at most. Visual analogue scales (VAS; 1-100 mm) were assessed by patients at rest and on coughing after 24 hr of CEI and PCEA. Side effects, doses of local anesthetics and opioids were recorded and plasma concentrations of total and unbound ropivacaine and bupivacaine were measured. RESULTS: Patients required lower doses of each respective analgesic medication with PCEA (R: 108 +/- 30 mL; BS: 110 +/- 28 mL) than with CEI (R: 234 +/- 40; BS: 260 +/- 45; P < 0.01). Ropivacaine plasma concentrations were lower 24 hr after PCEA when compared with CEI (P < 0.01). No patient after PCEA but two after CEI (n = 4; NS) presented motor block. PCEA with R provided better postoperative pain relief than CEI (37 +/- 32 vs 59+/-27, P < 0.05). No difference in parenteral opioid rescue medication between CEI and PCEA was seen. CONCLUSION: PCEA in comparison to preceding CEI provides equivalent analgesia with lower local anesthetic doses and plasma levels, and without motor blocking side effects, irrespective of the applied drug regimen.     

Safety and efficacy of a new filter-based protection system for aorto-coronary bypass graft interventions: the ev3 Spider device

PURPOSE: Treatment of aorto-coronary bypass grafts without a protection devices is associated with a high incidence of ischemic events. The Spider(R) system is a new protection device. METHODS AND RESULTS: We included 40 consecutive patients with 50 lesions and stenosis > 50% in bypass grafts. Follow-up was performed according to clinical records and by phone call after 30 days. Final TIMI flow 2 or 3 was observed in 97.5% of the patients, and no-reflow occurred in 10% without incidence of macroembolism. The technical success rate was 92.5%. A new rise of creatine kinase or troponin was observed in 27.5% after treatment, but 8 of 11 patients (72.7%) had only a periprocedural rise of troponin without elevation of creatine kinase. Debris was found in 52.5%, MACE rate was low (10%). Both types of stenoses (types A and B) were embolic, we found a trend for more frequent entrapped debris and periprocedural elevation of ischemic markers in type B stenoses, but these did not reach a significant level. CONCLUSION: Using the Spider system is feasible, and offers a high technical success rate, no macroembolism, and excellent final TIMI flow, but the risk of microembolism and periprocedural myocardial infarction is not entirely eliminated.     

Impact of the C2/C6 Ratio of High-molecular-weight Hydroxyethyl Starch on Pharmacokinetics and Blood Coagulation in Pigs

Background: High-molecular-weight, low-substituted hydroxyethyl starch (HES) may not affect blood coagulation more than low-molecular-weight, low-substituted HES. The authors assessed in vivo the effect of a lowered C2/C6 ratio on pharmacokinetic characteristics and the impact on blood coagulation of high-molecular-weight, low-substituted HES.

Methods: A prospective, randomized, parallel study in 30 pigs compared HES 650/0.42/2.8 with HES 650/0.42/5.6. Before, during, and after infusion of 30 ml/kg body weight HES, blood samples were collected over 630 min to measure HES concentrations and plasmatic coagulation and to assess blood coagulation in whole blood by Thrombelastography(R) (TEG(R); Haemoscope Corporation, Niles, IL). Pharmacokinetic parameters were estimated using a two-compartment model.

Results: The elimination constant was 0.009 +/- 0.001 min-1 for HES 650/0.42/2.8 and 0.007 +/- 0.001 min-1 for HES 650/0.42/5.6 (P < 0.001); the area under the plasma concentration-time curve was 1,374 +/- 340 min [middle dot] g/l for HES 650/0.42/2.8 and 1,697 +/- 411 min [middle dot] g/l for HES 650/0.42/5.6 (P = 0.026). The measured plasma HES concentrations were not different between HES 650/0.42/2.8 and HES 650/0.42/5.6. Both HES solutions equally affected blood coagulation: Thrombelastographic coagulation index decreased similarly at the end of infusion of HES 650/0.42/2.8 and at the end of infusion of HES 650/0.42/5.6 (P = 0.293). Also, activated partial thromboplastin and prothrombin times increased similarly for HES 650/0.42/2.8 and HES 650/0.42/5.6 (P = 0.831).     

Plasticity of synaptic ribbons of the rat pineal gland in vitro--minor effects of electrical stimulation.

Synaptic ribbons (SRs) of mammalian pinealocytes exhibit day/night changes in number and size, changes that are apparently regulated by the suprachiasmatic nucleus via postganglionic sympathetic nerve fibres. Since the neural control of SR changes is far from clear and as pinealocytes produce action potentials, we undertook to investigate whether electrical stimulation affects SR changes. Isolated rat pineal glands removed during the daytime were kept in vitro for 0, 30, 60, 90 or 120 min, with or without continuous electrical stimulation (1 mA, 1 Hz), followed by the quantification of SR profiles (SRPs) by transmission electron microscopy. SRs were categorised as to whether they lay less than 100 nm away from the pinealocyte plasmalemma (SRPs(near)) or more distant from it (SRPs(dist)) and the lengths of the profiles were measured. Cultured pineal organs showed a significant numerical depression of SRPs(near), irrespective of whether the organs had been electrically stimulated or not. SRPs(near) length revealed a significant increase at 60 min in unstimulated control tissue and at 30 min in electrically stimulated glands. SRPs(dist) length decreased significantly at 30 min in control glands and after 60 min in electrically stimulated glands. Thus, action potentials inside the pineal gland appear to be minor factors regulating SR numbers. In future pineal studies, SRPs(near) and SRPs(dist) should be considered separately as they differ in plasticity.