Long-term clinical outcomes after deployment of femoral vascular closure devices in coronary angiography and percutaneous coronary intervention: an observational single-centre registry follow-up.

OBJECTIVES: There are few data evaluating the long-term effect of femoral vascular closure devices (FCDs) on patients' clinical outcome. We aim to evaluate the incidence of peripheral vascular disease (PVD) in patients who received FCD following its deployment in coronary angiography and percutaneous coronary intervention (PCI) procedures. DESIGN AND SETTING: Observational study of a single-centre registry. PARTICIPANTS: From June 2000 to September 2004, 265 patients who received FCD after coronary angiography and PCIs were enrolled on the study. OUTCOME MEASURES: Clinical follow-up (using Rutherford's categories of claudication), ankle brachial index (ABI) and duplex ultrasound of femoral arteries (using the non-accessed side as control) were performed to evaluate the presence of PVD. RESULTS: The mean follow-up interval was 3320±628 days. 1 patient (0.4%) suffered from grade 2 claudication and another (0.4%) suffered from grade 1 claudication. The mean ABIs of the accessed side and non-accessed side were 1.06±0.13 and 1.08±0.11, respectively (p=0.17). For duplex ultrasound, the mean common femoral artery peak systolic velocities of the accessed side and non-accessed side were 87.4±22.3 and 87.7±22.1 cm/s, respectively (p=0.73); the mean superficial femoral artery peak systolic velocities of the accessed side and non-accessed side were 81.4±20.1 and 81.31±17.8 cm/s, respectively (p=0.19). CONCLUSIONS: The use of FCD after a coronary angiogram and PCI is safe and does not increase the long-term risk of PVD.

Lipid-lowering treatment in hypercholesterolaemic patients: the CEPHEUS Pan-Asian survey.

BACKGROUND: Treatment of hypercholesterolaemia in Asia is rarely evaluated on a large scale, and data on treatment outcome are scarce. The Pan-Asian CEPHEUS study aimed to assess low-density lipoprotein cholesterol (LDL-C) goal attainment among patients on lipid-lowering therapy. METHODS: This survey was conducted in eight Asian countries. Hypercholesterolaemic patients aged ≥18 years who had been on lipid-lowering treatment for ≥3 months (stable medication for ≥6 weeks) were recruited, and lipid concentrations were measured. Demographic and other clinically relevant information were collected, and the cardiovascular risk of each patient was determined. Definitions and criteria set by the updated 2004 National Cholesterol Education Program guidelines were applied. RESULTS: In this survey, 501 physicians enrolled 8064 patients, of whom 7281 were included in the final analysis. The mean age was 61.0 years, 44.4% were female, and 85.1% were on statin monotherapy. LDL-C goal attainment was reported in 49.1% of patients overall, including 51.2% of primary and 48.7% of secondary prevention patients, and 36.6% of patients with familial hypercholesterolaemia. The LDL-C goal was attained in 75.4% of moderate risk, 55.4% of high risk, and only 34.9% of very high-risk patients. Goal attainment was directly related to age and inversely related to cardiovascular risk and baseline LDL-C. CONCLUSION: A large proportion of Asian hypercholesterolaemic patients on lipid-lowering drugs are not at recommended LDL-C levels and remain at risk for cardiovascular disease. Given the proven efficacy of lipid-lowering drugs in the reduction of LDL-C, there is room for further optimization of treatments to maximize benefits and improve outcomes.

Type A aortic intramural hematoma: clinical features and outcomes in Chinese patients.

BACKGROUND: The purpose of this study was to describe the clinical characteristics and clinical outcomes for Chinese patients with type A intramural hematoma (IMH). METHODS AND RESULTS: We studied 90 patients with Stanford type A acute aortic syndrome who presented to our institution from 1998 to 2005 and evaluated the presentation, management, and clinical outcomes of acute IMH by comparing these patients with those diagnosed with classical aortic dissection (AD). A total of 34 patients had IMH and they tended to be older (69.7 ± 12.4 versus 60.5 ± 16.2 years; p=0.006). The development of pericardial effusion was more frequent in patients with IMH than in patients with AD. They were also less likely to receive surgery as compared to AD patients (26.5% versus 73.2%; p<0.0001). Overall mortality of IMH was not significantly higher than that of classic AD (29.4% versus 21.4%; p=0.45). For IMH patients, the mortality rate with medical treatment was 32%. Ten (40%) of the 25 medically treated patients developed adverse outcomes. However, no independent predictors of adverse outcomes were identified in the study. In follow-up imaging studies of 15 patients who survived IMH without surgical repair, 14 patients showed complete resolution of IMH and 1 progressed into classical AD. CONCLUSION: Acute type A IMH in Chinese patients showed a high mortality rate with medical treatment. It has a highly unpredictable course with no reliable clinical and anatomical predictors. Surgical therapy should be the treatment of choice for Chinese patients with acute IMH, especially those who are younger and have less comorbidities.

Dual coronary fistulas complicated with significant left to right heart shunt in an elderly patient.

Dual coronary artery fistula is a rare clinical entity and their clinical significance remains unknown. We hereby report a case of right coronary artery and left anterior descending artery fistula to pulmonary artery complicated with clinical significant left to right shunt (1.6:1) who remained clinically well at the age of 85 without percutaneous or surgical closure.

Long term clinical outcomes after deployment of femoral vascular closure devices in coronary angiography and percutaneous coronary intervention.

BACKGROUND: We evaluated the long term clinical outcomes of femoral vascular closure devices following its deployment in coronary angiography and percutaneous coronary intervention (PCI) procedures. METHODS: From June 2000 to September 2004, 265 patients who received femoral vascular closure devices after coronary angiography and PCIs were enrolled into the study. Patients' medical records were reviewed and vascular complications within 1 year of follow-up period were recorded. Rutherford's categories of claudication were used to quantify different degrees of claudication and leg ischaemia. Duplex ultrasonography of both femoral arteries (using the nonaccessed site as control) was performed at 1 year after deployment of vascular closure devices. Vessel diameter and flow velocities for both common femoral arteries were obtained. RESULTS: There was no occurrence of late vascular complications like arteriovenous fistula, pseudoaneurysm, surgical repair of access site complications, late groin bleeding and infection. By Rutherford categories of claudication, 99.2% of patients had grade 0 claudication while the remaining 0.8% was in grade 1. By arterial Duplex ultrasonography, the peak systolic velocity of the accessed femoral artery (predominantly right side) was nonsignificantly higher, 94.9 + or - 26.0 cm/s when compared to 91.5 + or - 24.8 cm/s in the control site (P = 0.12). As for vessel diameter, no significant difference was found in the mean end-diastolic vessel diameter 8.8 + or - 1.3 mm (puncture site) versus 8.7 + or - 4.4 mm (control site) (P = 0.72). CONCLUSION: We found that the use of femoral closure devices was safe and it was not associated with any adverse long term vascular complications.

New-onset heart failure after permanent right ventricular apical pacing in patients with acquired high-grade atrioventricular block and normal left ventricular function.

INTRODUCTION: Emerging data have suggested that right ventricular (RV) apical pacing results in progressive left ventricular (LV) dysfunction and contributes to the development of heart failure (HF). This study aimed to investigate the prevalence and clinical predictors for the development of new-onset HF after long-term RV apical pacing in patients with acquired atrioventricular (AV) block who require permanent pacing. METHODS: We studied the clinical outcomes after long-term RV apical pacing for acquired AV block in 304 patients without a prior history of HF. All patients had >90% ventricular pacing as determined by device diagnostic data. RESULTS: After a median follow-up of 7.8 years, 79 patients (26.0%) developed new-onset HF after RV apical pacing. Univariate Cox-regression analysis revealed that older age at the time of pacemaker implantation (P < 0.001), the presence of coronary artery disease (CAD) (P < 0.001) or atrial fibrillation (P = 0.03), VVI pacemaker (P < 0.001), wider paced QRS duration (P < 0.001), and new-onset myocardial infarction (P < 0.001) were predictors for HF. Multivariate analysis revealed that older age at implantation (Hazard ratio [HR] 1.06, 95% confidential interval [CI] 1.04-1.09, P < 0.001), CAD (HR 1.98, 95% CI 1.12-3.50, P < 0.05), and a wider paced QRS duration (HR 1.27 for each 10 ms increment, 95% CI 1.11-1.45, P = 0.001) were independent predictors of HF. Furthermore, cardiovascular mortality was significantly increased in those with HF (36.7% vs. 2.7%, P < 0.001). CONCLUSIONS: After a median follow-up of 7.8 years, permanent RV apical pacing was associated with HF in 26% of patients. Elderly age at the time of implant, a wider paced QRS duration and the presence of CAD independently predicted new-onset HF. More importantly, HF after RV apical pacing was associated with a higher cardiovascular mortality.

Cardiac resynchronization therapy optimization by ultrasonic cardiac output monitoring (USCOM) device.

OBJECTIVES: We investigated the accuracy and feasibility of a 2D echo-independent ultrasonic continuous wave Doppler cardiac output monitoring device (USCOM) operated by trained nurse for the atrio-ventricular interval (AVI) optimization in cardiac resynchronization therapy (CRT). BACKGROUND: CRT is of proven benefit in patients with advanced chronic heart failure and ventricular conduction delay. Appropriate AVI selection is critical to optimize hemodynamic in CRT. Currently, most non-invasive methods for AVI optimization are often complicated and labor-intensive. METHODS: USCOM method, Ritter method, and aortic outflow cardiac output method were used to determine the optima AVI in 20 patients with CRT. The accuracy and time for measurement of each method were determined. RESULTS: The optimal AVI determined by USCOM method had good correlation with Ritter's method and aortic outflow estimated cardiac output method (r2= 0.78, P < 0.01 and r2= 0.73, P < 0.01, respectively). The optimal AVI determined USCOM method showed good agreement (within 10 msec range) with Ritter's method (85% patients) and aortic outflow estimated cardiac output method (80%). The mean time for determining AVI using USCOM method was shorter than that with aortic outflow method (7.1 +/- 0.7 min vs 12.7 +/- 1.1 min, P < 0.01), whereas the mean time was shortest for Ritter method (4.7 +/- 1.6 min vs 7.1 +/- 0.7 min, P < 0.01). CONCLUSION: USCOM device operated by trained nurse can provide a simple, accurate, and fast non-invasive method for the AVI optimization in CRT population.

Emerging trends of community acquired infective endocarditis.

BACKGROUND: To obtain epidemiological information and to evaluate the emerging trend of incidence and clinical features of community acquired infective endocarditis (IE) in Hong Kong. METHODS: Population-based survey in a regional hospital in Hong Kong which served 0.55 million population over an 11-year period was conducted. 172 patients diagnosed to have IE between 1995 and 2005 were analyzed. Incidence, underlying heart disease, causative microorganisms and clinical outcomes of IE were studied. RESULTS: The standardized annual incidence of community acquired IE was 2.8 cases per 100,000 person-year and remain stable over the past 10 years in Hong Kong (P=0.57 for trends). The most common underlying heart diseases for IE were intravenous drug addict (30%), followed by chronic rheumatic heart disease (18%). There was a time trend of increasing age in patients suffered from IE, both in patients with or without intravenous drug abuse (overall P=0.004). Although there were no significant changes in the overall proportion of IE patients with different underlying etiologies, site of IE involvement and types of microorganisms, non-addict patients showed an increasing trend of staphylococcal IE during the study period (P=0.01). The adverse clinical outcome of IE during the study period remained unchanged (P=0.71). CONCLUSIONS: The results of this study have demonstrated that IE continued to be an important disease with stable incidence and high morbidity and mortality over time in Asia. Furthermore, our study also highlighted that IE is an emerging disease with continuously changing clinical and microbiologic patterns, and significant differences are still present between different countries.

The incremental benefit of rate-adaptive pacing on exercise performance during cardiac resynchronization therapy.

OBJECTIVES: The purpose of this research was to investigate the effect of using rate-adaptive pacing and atrioventricular interval (AVI) adaptation on exercise performance during cardiac resynchronization therapy (CRT). BACKGROUND: The potential incremental benefits of using rate-adaptive pacing and AVI adaptation with CRT during exercise have not been studied. METHODS: We studied 20 patients with heart failure, chronotropic incompetence (<85% age-predicted heart rate [AP-HR] and <80% HR reserve), and implanted with CRT. All patients underwent a cardiopulmonary exercise treadmill test using DDD mode with fixed AVI (DDD-OFF), DDD mode with adaptive AVI on (DDD-ON), and DDDR mode with adaptive AVI on (DDDR-ON) to measure metabolic equivalents (METs) and peak oxygen consumption (VO2max). RESULTS: During DDD-OFF mode, not all patients reached 85% AP-HR during exercise, and 55% of patients had <70% AP-HR. Compared to patients with >70% AP-HR, patients with <70% AP-HR had significantly lower baseline HR (66 +/- 3 beats/min vs. 80 +/- 5 beats/min, p = 0.015) and percentage HR reserve (27 +/- 5% vs. 48 +/- 6%, p = 0.006). In patients with <70% AP-HR, DDDR-ON mode increased peak exercise HR, exercise time, METs, and VO2max compared with DDD-OFF and DDD-ON modes (p < 0.05), without a significant difference between DDD-OFF and DDD-ON modes. In contrast, there were no significant differences in peak exercise HR, exercise time, METs, and VO2max among the three pacing modes in patients with >70% AP-HR. The percentage HR changes during exercise positively correlated with exercise time (r = 0.67, p < 0.001), METs (r = 0.56, p < 0.001), and VO2max (r = 0.55, p < 0.001). CONCLUSIONS: In heart failure patients with severe chronotropic incompetence as defined by failure to achieve >70% AP-HR, appropriate use of rate-adaptive pacing with CRT provides incremental benefit on exercise capacity during exercise.

Advances in devices for cardiac resynchronization in heart failure.

Patients with advanced heart failure have a high mortality and morbidity despite medical therapy. Depending on the underlying heart disease and severity of heart failure, 3.7 to 52.8% of patients have a QRS complex > or =120 ms who may have interventricular and intraventricular dyssynchrony correctible by cardiac resynchronization therapy (CRT). The latter is usually achieved with biventricular pacing, with the left ventricular lead placed in a tributary of the coronary sinus (CS), with a reported success rate between 88-92%. The technical advances for implantation include preformed guide sheaths to cannulate the CS, over the wire leads with passive fixation mechanism, and surgical placement methods. Device-specific CRT features include optimizing heart failure through insurance of a high percentage of pacing, heart failure monitoring, atrioventricular and interventricular timing, and avoiding double ventricular sensing. Furthermore, arrhythmic co-morbidities of heart failure such as atrial fibrillation and ventricular tachyarrhythmias can also be managed. Recent prospective trials suggest that there is a 30% reduction in heart failure hospitalization with CRT, and preliminary results suggest a survival benefit with CRT and implantable cardioverter defibrillator over optimal medical therapy.

Smoking, alcohol drinking and non-fatal coronary heart disease in Hong Kong Chinese.

PURPOSE: To examine whether smoking, alcohol drinking and other risk factors were associated with non-fatal coronary heart disease (CHD) in Hong Kong Chinese. METHODS: A case control study was carried out with 598 CHD hospital cases (431 men, 167 women) and 1100 community controls (663 men, 437 women). Standardized questionnaires were used and blood lipids were measured using standard methods. RESULTS: Stepwise logistic regression models showed adjusted odds ratios (AOR) of 3.36 [95% confidence interval (CI): 2.35 to 4.81] for smoking and 0.32 (95% CI: 0.22 to 0.45) for alcohol drinking in men, and 6.50 (95% CI: 2.61 to 16.19) and 0.15 (95% CI: 0.08 to 0.30), respectively, in women. The OR increased with decreasing levels of high-density lipoprotein cholesterol (HDL) and increasing levels of triglycerides. No patterns were observed for body mass index (BMI), total and low-density lipoprotein cholesterol (LDL). The protective effect of drinking was observed for different types of drinks and frequency of drinking, although few drank alcohol more than 3 days per week. CONCLUSIONS: Smoking was a strong risk factor and moderate alcohol drinking was a protective factor for CHD, and low HDL and high triglyceride levels were important risk factors in Hong Kong Chinese.