High Stroke Volume Para-aortic Counterpulsation Device versus Centrifugal Pump in Cardiogenic Shock: Experimental Study

p < 0.001), the tension time index (712 ± 381 versus 1333 ± 694, p < 0.01), and the double product (5629 ± 2574 versus 7440 ± 3294, p < 0.01) were significantly lower during assistance with the PACD than with the CBP. It was concluded that PACD is at least as effective as CBP for restoring hemodynamic status during acute experimental cardiogenic shock. Moreover, the PACD unloads the left ventricle more effectively than CBP, making it suitable for left ventricular mechanical support in cases with reversible myocardial damage.     

Dynamic hyperinflation and tolerance to interval exercise in patients with advanced COPD.

Dynamic hyperinflation (DH) contributes importantly to the limitation of constant-load exercise (CLE) in patients with chronic obstructive pulmonary disease (COPD). However, its role in the limitation of interval exercise (IE) remains to be explored. The change (Delta) in inspiratory capacity (IC) was measured to reflect changes in DH in 27 COPD patients (forced expiratory volume in one second mean+/-SEM % predicted: 40+/-3) at the end of a symptom-limited CLE test at 80% of peak work capacity (WRmax) and an IE test at 100% WRmax (30 s of work, alternated with 30 s of unloaded pedalling). At the limit of tolerance in both IE and CLE, patients exhibited similar DH (DeltaIC: 0.39+/-0.05 L and 0.45+/-0.05 L, respectively). However, exercise endurance time (t end) for IE (32.7+/-3.0 min) was significantly greater than for CLE (10.3+/-1.6 min). The IE t end correlated with resting IC, expressed as % pred normal. At 30 and 90% of total IE t end, DeltaIC (0.43+/-0.06 and 0.39+/-0.05 L, respectively) and minute ventilation (31.1+/-1.6 and 32.7+/-2.2 L.min(-1), respectively) were not significantly different. Resting hyperinflation helps to explain the limitation of interval exercise. Implementation of interval exercise for rehabilitation should provide important clinical benefits because it prolongs exercise endurance time and allows sustaining higher stable ventilation.     

Acute coronary and peripheral arterial thrombosis following percutaneous coronary intervention in a patient with previously undiagnosed inherited thrombophilia

Following pretreatment with ticlopidine 250 mg bid for three days, a 40-year-old man underwent successful angioplasty and stenting of the proximal left anterior descending coronary artery and balloon dilation of the midcircumflex coronary artery without stenting. He subsequently developed acute coronary thromboses at both arterial sites and cardiogenic shock. The patient survived after an additional percutaneous coronary intervention (PCI) and intra-aortic balloon pump assistance. This was followed by peripheral arterial thrombosis requiring repeated therapeutic interventions. Laboratory tests for thrombophilia revealed the presence of a G20210A prothrombin gene mutation. Two years later the patient remained free of angina and claudication, and underwent an unremarkable maximum exercise treadmill test. This is the first reported case of acute, multiple coronary and peripheral arterial thrombosis following PCI in a patient with previously unsuspected inherited thrombophilia. Inherited thrombophilia should be considered as a possible cause of arterial thrombosis following PCI.     

Adaptations of the peripheral circulation to PEEP.

The purpose of this study was to determine the role of changes in the parameters of venous return on the homeostatic adaption to the application of PEEP. We studied 13 dogs anesthetized with alpha-chloralose, intubated, and ventilated. We measured central venous pressure (CVP), arterial pressure (Pao) and cardiac output by thermal dilution. The cardiac output was transiently stopped by inflating a balloon in the right atrium, and the subsequent plateau in the CVP was used to obtain mean circulatory filling pressure (MCFP). Total blood volume was measured with Evans blue. To measure vascular capacitance and compliance, we rapidly infused 4 ml/kg or 8 ml/kg of blood and repeated the MCFP measurement. The same volume was withdrawn after the measurement. The volume and MCFP were used to construct pressure-volume (P-V) lines, and the unstressed volume was calculated by extrapolating the P-V to zero pressure. The P-V appeared linear in the range studied. PEEP produced a left shift of the curves and, thus, a decrease in unstressed volume. The shift with 20 cm H2O of PEEP was greater than with 10 cm H2O of PEEP. The rise in MCFP matched the rise in CVP so that the pressure gradient for venous return did not change. However, there was also an increase in the resistance to venous return, which resulted in a lower cardiac output than expected for the rise in MCFP. In conclusion, homeostatic adjustments to PEEP included a decrease in vascular capacitance, which is partially offset by a rise in the resistance to venous return.     

Thrombolysis and Counterpulsation to Improve Survival in Myocardial Infarction Complicated by Hypotension and Suspected Cardiogenic Shock or Heart Failure: Results of the TACTICS Trial

Background: Sustained hypotension, cardiogenic shock, and heart failure all imply a poor prognosis in acute myocardial infarction (MI). We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation (IABP) to standard treatment for MI, in an international trial among hospitals without primary angioplasty capabilities.Methods: We randomized 57 patients with MI complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure to receive either fibrinolytic therapy and IABP or fibrinolysis alone. The primary end point was all-cause mortality at 6 months.Results: In all, IABP was inserted in 27 of 30 assigned patients a median 30 minutes after fibrinolysis began and continued for a median 34 hours. Of the 27 patients assigned to fibrinolysis alone, 9 deteriorated such that IABP was required. The IABP group was at slightly higher risk at baseline, but the incidence of the primary end point did not differ significantly between groups (34% for combined treatment versus 43% for fibrinolysis alone; adjusted P = 0.23). Patients with Killip class III or IV showed a trend toward greater benefit from IABP (6-month mortality 39% for combined therapy versus 80% for fibrinolysis alone; P = 0.05).Conclusions: While early IABP use was not associated with a definitive survival benefit when added to fibrinolysis for patients with MI and hemodynamic compromise in this small trial, its use suggested a possible benefit for patients with the most severe heart failure or hypotension.Abbreviated Abstract. We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation to fibrinolytic therapy among 57 patients with acute myocardial infarction complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure. The primary end point, mortality at 6 months, did not differ between groups (34% for combined treatment versus 43% for fibrinolysis alone [n = 27]; adjusted P = 0.23), although patients with Killip class III or IV did show a trend toward greater benefit from IABP (39% for combined therapy versus 80% for fibrinolysis; P = 0.05).     

Characteristics and outcomes of cancer patients who develop pulmonary embolism: A cross-sectional study

Pulmonary embolism (PE), along with deep vein thrombosis, are collectively known as venous thromboembolism (VTE). Predisposing factors for PE include post-operative conditions, pregnancy, cancer and an advanced age; of note, a number of genetic mutations have been found to be associated with an increased risk of PE. The association between cancer and VTE is well-established, and cancer patients present a higher risk of a thrombotic event compared to the general population. In addition, PE is a significant cause of morbidity and mortality among cancer patients. The aim of the present study was to illustrate the clinical characteristics, laboratory findings, radiology features and outcomes of cancer patients who developed PE, collected from an anticancer hospital. For this purpose, adult cancer patients diagnosed with PE by imaging with computed tomography pulmonary angiography were enrolled. The following data were recorded: Demographics, comorbidities, type of cancer, time interval between cancer diagnosis and PE occurrence, the type of therapy received and the presence of metastases, clinical signs and symptoms, predisposing factors for PE development, laboratory data, radiological findings, electrocardiography findings, and the type of therapy received for PE and outcomes in a follow-up period of 6 months. In total, 60 cancer patients were enrolled. The majority of the cancer patients were males. The most common type of cancer observed was lung cancer. The majority of cases of PE occurred within the first year from the time of cancer diagnosis, while the majority of patients had already developed metastases. In addition, the majority of cancer patients had received chemotherapy over the past month, while they were not receiving anticoagulants and had central obstruction. A large proportion of patients had asymptomatic PE. The in-hospital mortality rate was 13.3% and no relapse or mortality were observed during the follow-up period. The present study demonstrates that elevated levels of lactic acid and an increased platelet count, as well as low serum levels of carcinoembryonic antigen, albumin and D-dimer, may be potential biomarkers for asymptomatic PE among cancer patients.     

Long-term experience with sotalol in the treatment of complex ventricular arrhythmias

Sotalol was given for extended therapy to 22 of 29 patients with frequent (greater than or equal to 30/hour) complex premature ventricular complexes (PVCs) who had participated in a short-term study of sotalol vs placebo. Open-label sotalol was given in individually titrated divided doses of 160 to 800 mg/day (median 323, mean 386 mg/day). Response was assessed at approximately 1, 6, and 12 months or until patient discontinuation. The period of sotalol therapy averaged 9 months (range, 0.2 to 22.7). At about 1 month, 13 (59%) of 22 patients showed effective control of arrhythmia. The median percentage change in total PVCs for individual patients at 1 month was -70% and for repetitive PVCs it was -95%. At about 6 months, 10 (45%) of the 22 patients continued to be successfully treated; at about 12 months, seven patients continued on sotalol, six (27%) successfully treated according to Holter criteria. Reasons for discontinuation included lack of efficacy in nine, adverse effects in four (fatigue in three, bradycardia with sinus pauses in one), and miscellaneous reasons in two. ECG PR and especially QTc intervals increased significantly during therapy (p less than 0.02, p less than 0.01, respectively). In summary, sotalol is a moderately effective antiarrhythmic agent in patients with complex PVCs, but during long-term therapy a rather high dropout rate was observed because of arrhythmia recurrence or adverse effects.     

Neuroticism personality trait is associated with Quality of Life in patients with Chronic Heart Failure

AIM: To evaluate Quality of life(QoL) in chronic heart failure(CHF) in relation to Neuroticism personality trait and CHF severity.METHODS: Thirty six consecutive, outpatients with Chronic Heart Failure(6 females and 30 males, mean age: 54 ± 12 years), with a left ventricular ejection fraction ≤ 45% at optimal medical treatment at the time of inclusion, were asked to answer the Kansas City Cardiomyopathy Questionnaire(KCCQ) for Quality ofLife assessment and the NEO Five-Factor Personality Inventory for personality assessment. All patients un-derwent a symptom limited cardiopulmonary exercise testing on a cycle-ergometer, in order to access CHF severity. A multivariate linear regression analysis us-ing simultaneous entry of predictors was performed to examine which of the CHF variables and of the person-ality variables were correlated independently to QoL scores in the two summary scales of the KCCQ, namely the Overall Summary Scale and the Clinical Summary Scale.RESULTS: The Neuroticism personality trait score had a significant inverse correlation with the Clinical Sum-mary Score and Overall Summary Score of the KCCQ(r =-0.621, P 0.05 and r =-0.543, P 0.001, respec-tively). KCCQ summary scales did not show significant correlations with the personality traits of Extraversion, Openness, Conscientiousness and Agreeableness. Mul-tivariate linear regression analysis using simultaneous entry of predictors was also conducted to determine the best linear combination of statistically significant univari-ate predictors such as Neuroticism, VE/VCO2 slope and VO2 peak, for predicting KCCQ Clinical Summary Score. The results show Neuroticism(β =-0.37, P 0.05), VE/VCO2 slope(β =-0.31, P 0.05) and VO2 peak(β = 0.37, P 0.05) to be independent predictors of QoL. In multivariate regression analysis Neuroticism(b =-0.37, P 0.05), the slope of ventilatory equivalent for carbon dioxide output during exercise,(VE/VCO2 slope)(b =-0.31, P 0.05) and peak oxygen uptake(VO2 peak),(b = 0.37, P 0.05) were independent predictors of QoL(adjusted R2 = 0.64; F = 18.89, P 0.001).CONCLUSION: Neuroticism is independently associat-ed with QoL in CHF. QoL in CHF is not only determined by disease severity but also by the Neuroticism person-ality trait.     

Effect of Psychosocial Interventions on Quality of Life in Patients With Chronic Heart Failure: A Meta-analysis of Randomized Controlled Trials

BackgroundPatients with chronic heart failure (CHF) usually experience poor quality of life (QoL). Psychosocial interventions tend to affect QoL in CHF. The aim of this study was to explore: 1) the effectiveness of psychosocial interventions on patients' QoL; 2) the magnitude of this effect; and 3) factors that appear to moderate the reported effect on QoL.Methods and ResultsMeta-analysis of the data of 1,074 intervention patients and 1,106 control patients from 16 randomized controlled trials (RCTs) that reported QoL measures in treatment and control groups before and after a psychosocial intervention. Subgroup analyses were conducted between: 1) face-to-face versus telephone interventions; 2) interventions that included only patients versus those that included patients and their caregivers; and 3) interventions conducted by a physician and a nurse only, versus those conducted by a multidisciplinary team. Psychosocial interventions improved QoL of CHF patients (standardized mean difference 0.46, confidence interval [CI] 0.19–0.72; P < .001). Face-to-face interventions showed greater QoL improvement compared with telephone interventions (χ² = 5.73; df = 1; P < .02). Interventions that included caregivers did not appear to be significantly more effective (χ² = 1.12; df = 1; P > .29). A trend was found for multidisciplinary team approaches being more effective compared with nonmultidisciplinary approaches (χ² = 1.96; df = 1; P = .16).ConclusionsA significant overall QoL improvement emerged after conducting psychosocial interventions with CHF patients. Interventions based on a face-to-face approach showed greater benefit for patients' QoL compared with telephone-based approaches. No significant advantage was found for interventions conducted by a multidisciplinary team compared with a physician and nurse approach, or for psychosocial interventions which included patients' caregivers compared with patient-only approaches.