Effects of verapamil and adenosine in an adjunct to tirofiban on resolution and prognosis of noreflow phenomenon in patients with acute myocardial infarction.

AIM: We aimed to investigate the effects of verapamil and adenosine in an adjunct to intravenous tirofiban on management and prognosis of no-reflow phenomenon during primary percutaneous coronary intervention (PPCI) and to compare their efficacies on reversing of no-reflow phenomenon and short and midterm survival. METHODS: We included 46 patients with acute ST-segment elevation myocardial infarction (STEMI) and occurrence of no-reflow phenomenon after PPCI. All patients received intravenous tirofiban and then randomized into one of the following 3 groups: intracoronary adenosine (N.=16), intracoronary verapamil (N.=15) or placebo (N.=15). RESULTS: Intracoronary verapamil therapy had significant effect in restoring impaired coronary blood flow by decreasing thrombolysis in myocardial infarction (TIMI) frame count from 73±44 to 52±48 (P=0.024). However, adenosine and serum physiologic administration were not found to be so effective in decreasing TIMI frame count (from 81±35 to 71±46, P=0.084; from 74±32 to 71±37, P=0.612, respectively). In-hospital and 6-month survival rates were similar among groups. CONCLUSION: In conclusion, intracoronary verapamil restored the impaired coronary blood flow more effectively than adenosine or placebo. However, none of them has changed the clinical course in the first 6 months.

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. METHODS: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. RESULTS: The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died. CONCLUSION: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.

Left atrial thrombus detection with multiplane transesophageal echocardiography: an echocardiographic study with surgical verification.

BACKGROUND AND AIM OF THE STUDY: The detection of left atrial thrombus (LAT) is especially important in patients being evaluated for percutaneous mitral valvuloplasty and elective cardioversion for atrial fibrillation. Transesophageal echocardiography (TEE) is widely used for this indication. This study was undertaken to validate the use of multiplane TEE to detect LAT in the setting of rheumatic mitral valve disease. METHODS: The study population comprised 262 patients (103 men, 159 women, mean age 42.2+/-13.1 years) who underwent open heart surgery for rheumatic mitral valvular disease between January 1994 and October 1997. Of these patients, 178 had mitral stenosis and 84 mitral regurgitation. All patients were examined with multiplane TEE less than three days before valvular surgery. RESULTS: The presence or absence of LAT was confirmed at surgery by direct inspection of the left atrium. Left atrial thrombi were detected by TEE in 34 patients (14 men, 20 women; mean age 51+/-8 years). The presence of all 34 thrombi found by multiplane TEE was confirmed during surgery. Only one thrombus was confirmed surgically among 228 patients shown thrombus-negative by multiplane TEE. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for multiplane TEE were 97, 100, 100, 99.6 and 99.6%, respectively. CONCLUSION: Multiplane TEE is exquisitely sensitive for the detection of LAT.

The influence of the resolution of reciprocal ST segment changes on in-hospital complications of acute myocardial infarction after percutaneous coronary angioplasty.

We studied 120 patients (M:F 105:15, mean age 57.5 +/- 10.1 years) with acute myocardial infarction (MI) successfully treated with percutaneous coronary angioplasty (PTCA) to analyze the influence of the resolution of the ST segment elevation and depression after intervention to 1 month composite endpoints of reinfarction or reocclusion, development of congestive heart failure (CF) and death. Sum of preintervention and postintervention ST segment elevation and depression and the rate of resolution of these ST segment elevations and depressions were recorded for every patient. A total of 17 (14.2%) composite endpoint events (events group) were recorded (7 reocclusion or recurrent MI, 9 CF, and 1 death). On univariate analysis, events group patients were older (53.3 +/- 9.9 vs. 58.8 +/- 9.1 years, P = 0.032), had lesser resolution of ST segment elevations (85 +/- 24% vs. 44 +/- 55%, P = 0.017) and depression (72 +/- 26% vs. 52 +/- 30%, P = 0.009), had greater preintervention ST segment elevation (17.49 +/- 12.95 mm vs. 28.38 +/- 20.41 mm, P = 0.045), had lower ejection fraction (59.3 +/- 10.2% vs. 43.6 +/- 9.4%, P < 0.001), and had more frequent multivessel disease (71% vs. 47%, P = 0.048) compared to the nonevents group. Time from angina to reperfusion, residual stenosis, sex, infarct location and infarct-related vessel distribution were similar. On multivariate analysis (logistic regression with backward likelihood ratio) only older age (P = 0.0752), lesser rate of resolution of ST segment depression (P = 0.0262) and lower ejection fractions (P = 0.0014) were retained as predictors of the composite endpoints. Relative risk conferred by less than 50% resolution of ST segment depressions for composite endpoints were 3.78 (95% CI 1.63-8.73). We conclude that the lack of resolution of the sum of reciprocal ST segment depressions identifies a subgroup of acute MI patients with greater morbidity after primary PTCA.

Persistence of left atrial spontaneous echocardiographic contrast after percutaneous mitral valvulotomy: a study in the Turkish population.

We evaluated the resolution of left atrial spontaneous echocardiographic contrast (SEC) using transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) one day before and three days after percutaneous mitral balloon valvulotomy (PMV) in 56 consecutive patients with mitral stenosis. SEC was present in 43 patients (77%) before the procedure. We associated the following parameters with pre-procedure SEC; decreased forward (p = 0.043) and backward (p = 0.044) left atrial appendage (LAA) peak flow velocities, increased left atrial dimension (p = 0.05), decreased mitral valve area (p = 0.001), presence of atrial fibrillation (p = 0.031), and increased pulmonary systolic pressure (p = 0.01). In multivariate analysis, decreased forward LAA peak flow velocity (p = 0.0724), and decreased mitral valve area (p = 0.0026) were the significant independent predictors for the presence of pre-procedure SEC. On post-PMV transesophageal echocardiography, SEC was present in seven patients (13%). Analysis of this subgroup of patients showed them to be in the lowest quintile of the preprocedure forward LAA peak flow velocities. They also showed smaller percentage and absolute increase in backward LAA peak flow velocities after PMV. We suggest continued left atrial muscular dysfunction as an explanation for the persistence of SEC, despite the excellent hemodynamic improvement. We explain the dramatic decrease in SEC after PMV, on the basis of the youth of our patient population, the high success rates attained with PMV, and the physiopathologic mechanisms that may be in play in rheumatic mitral stenosis seen in developing countries.

Percutaneous mitral valvulotomy in the presence of atrial septal aneurysm.

In this report, we discuss the feasibility of percutaneous mitral valvulotomy in the presence of mitral stenosis and concomitant atrial septal aneurysm. Our data suggest that percutaneous mitral valvulotomy can be safely performed if the atrial septal aneurysm does not involve the entire interatrial septum.