ABSTRACT
Right ventricular infarction (RVI) complicates 50% of cases of acute inferior ST-segment elevation myocardial infarction, and is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. RV systolic performance is generated by left ventricular contractile contributions mediated by the septum. Augmented right atrial contraction optimizes RV performance, whereas very proximal occlusions induce right atrial ischemia exacerbating hemodynamic compromise. RVI is associated with vagal mediated bradyarrhythmias, both during acute occlusion and abruptly with reperfusion. The ischemic dilated RV is also prone to malignant ventricular arrhythmias. Nevertheless, RV is remarkably resistant to infarction. Reperfusion facilitates RV recovery, even after prolonged occlusion and in patients with severe shock. However, in some cases hemodynamic compromise persists, necessitating pharmacological and mechanical circulatory support with dedicated RV assist devices as a "bridge to recovery."
Subject(s)
Heart Ventricles , Ventricular Dysfunction, Right , Humans , Ventricular Dysfunction, Right/physiopathology , Ventricular Dysfunction, Right/etiology , Heart Ventricles/physiopathology , Myocardial Infarction/physiopathologyABSTRACT
OBJECTIVES: This study evaluated the efficacy of a novel comprehensive shield designed to minimize radiation exposure (RE) to Physicians performing coronary and structural heart procedures. BACKGROUND: The Protego™ radiation shielding system (Image Diagnostics Inc., Fitchburg, Ma) is designed to provide comprehensive protection from RE and has been State certified sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. METHODS: This single center two-group cohort study assessed the efficacy of this shield in a large number of cardiac procedures (coronary and structural), comparing operator RE compared to standard protection methods (personal lead apparel and "drop down" shield). RESULTS: The Protego™ system reduced operator RE by 99 % compared to Standard Protection. RE was significantly lower at both "Head" level by thyroid median dose 0.0 (0.0, 0,0) vs 5.7 (2.9, 8.2) µSv (p < 0.001), as well as waist dose 0.0 (0.0, 0.0) vs 10.0 (5.0, 16.6) µSv (p < 0.001). "Zero" Total RE was documented by Raysafe™ in 64 % (n = 32) of TAVR cases and 73.2 % (n = 183) of the coronary cases utilizing Protego™. In contrast, standard protection did not achieve "Zero" exposure in a single case. These dramatic differences in RE were achieved despite higher fluoroscopy times in the Protego™ arm (11.9 ± 8.6 vs 14.3 ± 12.5 min, p = 0.015). Per case procedural exposure measured by Dose Area Product was higher in the Protego™ group compared to standard protection (115.4 ± 139.2 vs 74.9 ± 69.3, p < 0.001). CONCLUSION: The Protego™ shield provides total body RE protection for operators performing both coronary and structural heart procedures. This shield allows procedural performance without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.
Subject(s)
Occupational Exposure , Occupational Health , Radiation Dosage , Radiation Exposure , Radiation Protection , Radiography, Interventional , Humans , Occupational Exposure/prevention & control , Occupational Exposure/adverse effects , Radiation Exposure/prevention & control , Radiation Exposure/adverse effects , Radiation Protection/instrumentation , Radiography, Interventional/adverse effects , Radiography, Interventional/standards , Risk Factors , Risk Assessment , Radiation Injuries/prevention & control , Radiation Injuries/etiology , Equipment Design , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Male , Radiation Monitoring , FemaleSubject(s)
Cardiac Surgical Procedures , Heart Valve Prosthesis Implantation , Tricuspid Valve Insufficiency , Humans , Tricuspid Valve Insufficiency/diagnostic imaging , Tricuspid Valve Insufficiency/etiology , Tricuspid Valve Insufficiency/surgery , Tricuspid Valve/diagnostic imaging , Tricuspid Valve/surgery , Tricuspid Valve/physiopathology , Treatment Outcome , Heart Valve Prosthesis Implantation/adverse effects , CathetersSubject(s)
Aortic Valve Stenosis , Coronary Artery Disease , Percutaneous Coronary Intervention , Transcatheter Aortic Valve Replacement , Humans , Transcatheter Aortic Valve Replacement/adverse effects , Treatment Outcome , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Coronary Artery Disease/surgery , Percutaneous Coronary Intervention/adverse effects , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Risk FactorsABSTRACT
We report a patient with severe mitral annular calcification, mitral stenosis/regurgitation, hypertrophic obstructive cardiomyopathy, and subaortic membrane treated with valved left atrium-left ventricle conduit, septal myectomy, and membrane resection. Subsequent thrombosis of the conduit prompted successful valve-in- mitral annular calcification transcatheter mitral valve replacement and laceration of the anterior mitral leaflet to prevent outflow obstruction. (Level of Difficulty: Advanced.).
Subject(s)
Acute Coronary Syndrome , Coronary Artery Disease , Percutaneous Coronary Intervention , Coronary Angiography , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/therapy , Death, Sudden, Cardiac/etiology , Death, Sudden, Cardiac/prevention & control , Humans , Myocardium , Treatment OutcomeABSTRACT
In acute pulmonary embolism (PE), low cardiac output (CO)-hypotension results from disparate ventricular conditions: The left ventricle (LV) is under-filled and contracting vigorously, whereas the right ventricle (RV) is failing and dilated. The proximate cause of LV preload deprivation is thrombus-induced pulmonary vascular obstruction; abruptly increased pulmonary vascular resistance (PVR) induces acute RV systolic dysfunction which further compromises trans-pulmonary flow. "Escalation of Care" interventions (thrombolytics and aspiration thrombectomy) improve systemic hemodynamics by increasing LV preload delivery directly by reducing PVR and indirectly by relief of the strained failing RV.
Subject(s)
Pulmonary Embolism , Ventricular Dysfunction, Right , Heart Ventricles , Hemodynamics , Humans , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/therapy , Treatment Outcome , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/therapyABSTRACT
In asymptomatic severe aortic (AR) and mitral regurgitation (MR), left ventricular (LV) dimension criteria were established to guide timing of valve replacement to prevent irreversible LV dysfunction. Given both lesions are primary LV volume overload ''leaks'', it might be expected that both lesions would induce similar impact on the LV and result in equivalent dimension criteria for intervention. However, the dimension-based intervention criteria for AR versus MR (developed through natural history studies), differ markedly. The pathophysiological foundations for such discordance have neither been fully elucidated nor emphasized. This case-based treatise compares the two regurgitant lesions with respect to: (a) ''total regurgitant circuits''; (b) ''driving pressures'' resulting in LV volume overload from each respective ''leak''; and (c) volume and afterload wall stresses imposed on the LV.Key points The ''total circuits'' of volume overload differ: The AR circuit includes the LV and systemic vasculature, whereas MR includes the LV ejecting into the left atrium/pulmonary veins and systemic circulation. The ''driving pressure'' of regurgitation and afterload are high with AR and low with MR. Differing ''total circuits'' and ''driving pressures'' impose disparate wall stresses upon the LV. Parallel and serial sarcomere replication occurs in AR, while only serial replication occurs in MR. It therefore follows that for regurgitation of similar severities, AR results in greater LV dilation at the point of irreversible myocardial dysfunction compared to MR. These considerations may explain, at least in part, the disparate dimension criteria employed for valve intervention for severe AR vs MR.
Subject(s)
Aortic Valve Insufficiency , Mitral Valve Insufficiency , Ventricular Dysfunction, Left , Aortic Valve Insufficiency/diagnostic imaging , Aortic Valve Insufficiency/etiology , Aortic Valve Insufficiency/surgery , Dilatation , Humans , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/surgery , Treatment OutcomeABSTRACT
Rapid restoration of hemodynamics is key to successful shock management. The failing right ventricular (RV) is resilient and recovers if hemodynamics are supported while the underlying insulting cause is alleviated. Inotropic/vasopressor drugs constitute a "double-edged sword" that augment hemodynamics, but exacerbate myocardial and multiorgan injury. Impella RP mechanical support for RV shock stabilizes hemodynamics and is associated with favorable clinical outcomes.
Subject(s)
Heart Failure , Heart-Assist Devices , Ventricular Dysfunction, Right , Adolescent , Heart Ventricles , Heart-Assist Devices/adverse effects , Hemodynamics , Humans , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Treatment Outcome , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/therapy , Young AdultABSTRACT
Evaluating the hemodynamic performance of aortic valve prostheses has relied primarily on echocardiography. This involves calculating the trans-prosthetic valve mean gradient (MG) and aortic valve area (AVA), and assessing for valvular and paravalvular regurgitation in a fashion similar to the native aortic valve. In conjunction with other echocardiographic and nonechocardiographic parameters, MG and AVA are used to distinguish between prosthesis stenosis, prosthesis patient mismatch, pressure recovery, increased flow, and measurement errors. This review will discuss the principles and limitations of echocardiographic evaluation of aortic valve prosthesis following surgical, and transcatheter aortic valve replacement and in comparison to invasive hemodynamics through illustrative clinical cases.
Subject(s)
Aortic Valve Insufficiency , Aortic Valve Stenosis , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Insufficiency/diagnostic imaging , Aortic Valve Insufficiency/surgery , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Cardiac Catheterization , Hemodynamics , Humans , Prosthesis Design , Severity of Illness Index , Treatment OutcomeSubject(s)
Cardiac Catheterization/methods , Cardiology Service, Hospital/standards , Health Personnel , Laboratories, Hospital/standards , Occupational Diseases , Occupational Health/standards , Fluoroscopy/adverse effects , Fluoroscopy/methods , Humans , Occupational Diseases/etiology , Occupational Diseases/prevention & control , Radiation Monitoring , Safety Management/methods , Safety Management/organization & administrationABSTRACT
BACKGROUND: Autopsy studies suggest that implanting stents in lipid-rich plaque (LRP) may be associated with adverse outcomes. OBJECTIVES: The purpose of this study was to evaluate the association between LRP detected by near-infrared spectroscopy (NIRS) and clinical outcomes in patients with coronary artery disease treated with contemporary drug-eluting stents. METHODS: In this prospective, multicenter registry, NIRS was performed in patients undergoing coronary angiography and possible percutaneous coronary intervention (PCI). Lipid core burden index (LCBI) was calculated as the fraction of pixels with the probability of LRP >0.6 within a region of interest. MaxLCBI4mm was defined as the maximum LCBI within any 4-mm-long segment. Major adverse cardiac events (MACE) included cardiac death, myocardial infarction, definite or probable stent thrombosis, or unplanned revascularization or rehospitalization for progressive angina or unstable angina. Events were subcategorized as culprit (treated) lesion-related, nonculprit (untreated) lesion-related, or indeterminate. RESULTS: Among 1,999 patients who were enrolled in the COLOR (Chemometric Observations of Lipid Core Plaques of Interest in Native Coronary Arteries Registry), PCI was performed in 1,621 patients and MACE occurred in 18.0% of patients, of which 8.3% were culprit lesion-related, 10.7% were nonculprit lesion-related, and 3.1% were indeterminate during 2-year follow-up. Complications from NIRS imaging occurred in 9 patients (0.45%), which resulted in 1 peri-procedural myocardial infarction and 1 emergent coronary bypass. Pre-PCI NIRS imaging was obtained in 1,189 patients, and the 2-year rate of culprit lesion-related MACE was not significantly associated with maxLCBI4mm (hazard ratio of maxLCBI4mm per 100: 1.06; 95% confidence interval: 0.96 to 1.17; p = 0.28) after adjusting clinical and procedural factors. CONCLUSIONS: Following PCI with contemporary drug-eluting stents, stent implantation in NIRS-defined LRPs was not associated with increased periprocedural or late adverse outcomes compared with those without significant lipid.
Subject(s)
Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/metabolism , Drug-Eluting Stents/trends , Percutaneous Coronary Intervention/trends , Plaque, Atherosclerotic/diagnostic imaging , Plaque, Atherosclerotic/metabolism , Aged , Drug-Eluting Stents/adverse effects , Female , Follow-Up Studies , Humans , Lipid Metabolism/physiology , Male , Middle Aged , Percutaneous Coronary Intervention/adverse effects , Prospective Studies , Registries , Spectroscopy, Near-Infrared/trends , Treatment OutcomeSubject(s)
Cardiac Tamponade/surgery , Pericardial Effusion , Echocardiography , Humans , Pericardiocentesis , Treatment Outcome , United StatesSubject(s)
Cardiac Catheterization/standards , Musculoskeletal Diseases/prevention & control , Occupational Exposure/prevention & control , Occupational Health/standards , Radiation Exposure/prevention & control , Radiation Injuries/prevention & control , Radiography, Interventional/standards , Cardiac Catheterization/adverse effects , Consensus , Humans , Musculoskeletal Diseases/epidemiology , Occupational Exposure/adverse effects , Protective Factors , Radiation Exposure/adverse effects , Radiation Injuries/epidemiology , Radiography, Interventional/adverse effects , Risk Assessment , Risk FactorsABSTRACT
BACKGROUND: Transcranial electrical stimulation has broad potential as a treatment for depression. Transcranial random noise stimulation, which delivers randomly fluctuating current intensities, may have greater cortical excitatory effects compared with other forms of transcranial electrical stimulation. We therefore aimed to investigate the antidepressant efficacy of transcranial random noise stimulation. METHODS: Depressed participants were randomly assigned by computer number generator to receive 20 sessions of either active or sham transcranial random noise stimulation over 4 weeks in a double-blinded, parallel group randomized-controlled trial. Transcranial random noise stimulation was delivered for 30 minutes with a direct current offset of 2 mA and a random noise range of 2 mA. Primary analyses assessed changes in depression severity using the Montgomery-Asperg Depression Rating Scale. Neuroplasticity, neuropsychological, and safety outcomes were analyzed as secondary measures. RESULTS: Sixty-nine participants were randomized, of which 3 discontinued treatment early, leaving 66 (sham n = 34, active n = 32) for per-protocol analysis. Depression severity scores reduced in both groups (Montgomery-Asperg Depression Rating Scale reduction in sham = 7.0 [95% CI = 5.0-8.9]; and active = 5.2 [95% CI = 3.2-7.3]). However, there were no differences between active and sham groups in the reduction of depressive symptoms or the number of participants meeting response (sham = 14.7%; active = 3.1%) and remission criteria (sham = 5.9%; active = 0%). Erythema, paresthesia, fatigue, and dizziness/light-headedness occurred more frequently in the active transcranial random noise stimulation group. Neuroplasticity, neuropsychological, and acute cognitive effects were comparable between groups. CONCLUSION: Our results do not support the use of transcranial random noise stimulation with the current stimulation parameters as a therapeutic intervention for the treatment of depression. CLINICAL TRIAL REGISTRATION AT CLINICALTRIALS: gov/NCT01792414.