ABSTRACT
AIMS: The aim of this study was to evaluate the safety and efficacy of the EkoSonic Endovascular System (EKOS) in patients with acute pulmonary embolism (APE) at high or intermediate-high risk and contraindication to systemic fibrinolysis. METHODS: This is a retrospective study including consecutive patients admitted due to high-risk or intermediate-high-risk APE and treated by EKOS because of an absolute or relative contraindication to systemic fibrinolysis. The primary efficacy end-point was the change from baseline to 72âh in right to left ventricular dimension ratio [right ventricular/left ventricular (RV/LV) ratio]; pulmonary embolic burden using the Qanadli Index; and systolic pulmonary arterial pressure (SPAP). The primary safety end-point was the occurrence of bleeding (GUSTO classification) within 72âh. RESULTS: Eighteen patients (5 men, 13 women; mean age 74â±â12.7 years) affected by high-risk APE (nâ=â5; 27.8%) or intermediate-high-risk APE (nâ=â13; 72.2%) were included. A significant reduction of mean RV/LV ratio (1.38â±â0.3 vs. 0.97â±â0.16; Pâ<â0.0005); Qanadli Index [27.06â±â2.6 vs. 18.8â±â7.8 (Pâ<â0.001) and SPAP (71.1â±â12 vs. 45.2â±â16âmmHg; Pâ<â0.001)] was observed within 72âh after EKOS. Five bleeding events occurred: one fatal and four moderates; three out of them led to the access site hematoma, two due to pre-existing active bleeding. CONCLUSION: EKOS is an effective tool to treat patients with APE at high or intermediate-high risk and contraindication to fibrinolysis. It is a relatively safe therapy considering the critical conditions and high bleeding risk of the receiving population.
Subject(s)
Endovascular Procedures/instrumentation , Fibrinolytic Agents/adverse effects , Mechanical Thrombolysis/instrumentation , Pulmonary Embolism/therapy , Thrombolytic Therapy/adverse effects , Ultrasonic Therapy/instrumentation , Acute Disease , Aged , Aged, 80 and over , Contraindications, Drug , Endovascular Procedures/adverse effects , Endovascular Procedures/mortality , Female , Hemodynamics , Hemorrhage/etiology , Humans , Male , Mechanical Thrombolysis/adverse effects , Mechanical Thrombolysis/mortality , Middle Aged , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/mortality , Pulmonary Embolism/physiopathology , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Ultrasonic Therapy/adverse effects , Ultrasonic Therapy/mortality , Ventricular Function, Left , Ventricular Function, RightABSTRACT
BACKGROUND: Limited evidence is available about MitraClip therapy in patients with acute mitral regurgitation (MR) complicating myocardial infarction (MI). METHODS AND RESULTS: Among 80 consecutive patients undergoing MitraClip treatment, 5 (6.3%) had been admitted for acute MI complicated by severe MR. Mean age was 73±6years and 3 were males. At the time of admission they were in cardiogenic shock (80%) or pulmonary oedema (20%), with severe MR, left ventricular dysfunction and pulmonary hypertension. The indication to MitraClip treatment was based on severe hemodynamic instability with dependence on intravenous therapy and mechanical supports despite percutaneous coronary revascularization and on high surgical risk of 27.1±13% and 10.2±6% using Euroscore II and STS score respectively. MitraClip procedure was performed at 53±33days from admission. One or two clips were employed in 2 and 3 patients respectively. Procedural success (MR≤2+) was achieved in all patients without complications and with successful weaning from mechanical supports and intravenous drugs in all but one patient who underwent left ventricular assist device implantation at 60days from MitraClip procedure. MR recurrence occurred at 30-day follow-up in one patient who had concomitant aortic regurgitation. One patient died during follow-up for non-cardiovascular cause. However, recovery of hemodynamic balance with significant and persistent pulmonary pressure reduction and functional status improvement up to 2-year follow-up was observed in most of the patients. CONCLUSIONS: Critical patients with acute ischemic MR post-MI with persistence of hemodynamic instability after coronary revascularization may benefit from MitraClip therapy acutely with favourable long-term follow-up results.
Subject(s)
Cardiac Surgical Procedures/methods , Mitral Valve Insufficiency , Mitral Valve , Myocardial Infarction/complications , Acute Disease , Aged , Aged, 80 and over , Female , Follow-Up Studies , Hemodynamics , Humans , Italy , Male , Middle Aged , Mitral Valve/diagnostic imaging , Mitral Valve/physiopathology , Mitral Valve/surgery , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/physiopathology , Mitral Valve Insufficiency/surgery , Myocardial Infarction/diagnosis , Pulmonary Edema/etiology , Pulmonary Edema/therapy , Risk Assessment , Severity of Illness Index , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Treatment OutcomeSubject(s)
Aortic Valve Stenosis/diagnostic imaging , Echocardiography, Doppler/trends , Severity of Illness Index , Adult , Aged , Aged, 80 and over , Aortic Valve Stenosis/mortality , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prognosis , Retrospective Studies , Survival Rate/trends , Time FactorsABSTRACT
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and is associated with a significantly increased risk of thromboembolic events and mortality. From the age of 50 years, prevalence of AF doubles every 10 years, being more common in males and reaching 5.9% in patients 65 years and older. The treatment of AF has as first objective the restoration and maintenance of sinus rhythm. The drugs used to date present several limitations in terms of side and pro-arrhythmic effects, associated with a limited antiarrhythmic effect. Recent European guidelines for the management of AF have pointed out that the pharmacological antiarrhythmic therapy to maintain sinus rhythm is helpful for symptoms related to the arrhythmia. Amiodarone is the drug with the greatest potential for maintenance of sinus rhythm in the older population as well. Other drugs currently in use are flecainide, propafenone, sotalol, and more recently introduced dronedarone and vernakalant. To date, there is no consensus among scientific societies on the management of AF: for elderly patients, who account for the majority of patients with AF, a strictly individualized evaluation is mandatory.
