ABSTRACT
Percutaneous left ventricular assist device (pLVAD) utilization is increasing as the potential applications expand. We report a case of high-risk balloon aortic valvuloplasty and percutaneous coronary intervention using the Impella 2.5 pLVAD in a patient with severely depressed left ventricular function as a bridge to heart transplantation.
Subject(s)
Angioplasty, Balloon, Coronary/instrumentation , Aortic Valve Stenosis/therapy , Heart Failure/therapy , Heart Transplantation , Heart-Assist Devices , Angioplasty, Balloon, Coronary/methods , Coronary Stenosis/therapy , Heart Failure/surgery , Humans , Male , Middle Aged , Stents , Ventricular Dysfunction, Left/therapyABSTRACT
BACKGROUND: Pharmacokinetic data suggests that the intravenous form of n-acetylcysteine (NAC) may be more effective than the oral formulation in preventing contrast induced nephropathy (CIN). NAC owing to its anti-oxidant properties might be beneficial for patients with acute coronary syndromes (ACS) who are at increased risk for CIN. The aim of this prospective randomized, single-center, double-blind, placebo controlled trial (NCT00939913) was to assess the effect of high-dose intravenous NAC on CIN in ACS patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI). METHODS: We randomized 398 ACS patients scheduled for diagnostic angiography ± PCI to an intravenous regimen of high-dose NAC (1,200 mg bolus followed by 200 mg/hr for 24 hr; n = 206) or placebo (n = 192). The primary end-point was incidence of CIN defined as an increase in serum creatinine concentration ≥ 25% above the baseline level within 72 hr of the administration of intravenous contrast. RESULTS: There was no difference found for the primary end point with CIN in 16% of the NAC group and in 13% of the placebo group (p = 0.40). Change in serum cystatin-C, a sensitive marker for renal function, was 0.046 ± 0.204 in the NAC group and 0.002 ± 0.260 in the control group (p = 0.07). CONCLUSION: In ACS patients undergoing angiography ± PCI, high-dose intravenous NAC failed to reduce the incidence of CIN.
Subject(s)
Acetylcysteine/administration & dosage , Acute Coronary Syndrome/diagnostic imaging , Angioplasty, Balloon, Coronary , Antioxidants/administration & dosage , Contrast Media/adverse effects , Coronary Angiography/adverse effects , Kidney Diseases/prevention & control , Acute Coronary Syndrome/therapy , Aged , Biomarkers/blood , Chi-Square Distribution , Creatinine/blood , Cystatin C/blood , Double-Blind Method , Female , Humans , Infusions, Intravenous , Kidney Diseases/blood , Kidney Diseases/chemically induced , Kidney Diseases/diagnosis , Male , Middle Aged , New Orleans , Placebos , Prospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
Clinically evident and subclinical peri-procedural bleeding following interventional therapies are associated with adverse cardiovascular outcomes. The risk factors for clinically evident bleeding have been well described. Despite the well-documented association of adverse outcomes for patients with a subclinical peri-procedural hemoglobin drop, the clinical predictors have not yet been defined. We identified 1176 consecutive patients with a subclinical drop in hemoglobin (fall of ≥ 1 g/dl in patients without clinical bleeding) following percutaneous coronary interventions (PCI) and peripheral vascular interventions (PVI). Multivariate logistic regression analysis was performed. A subclinical peri-procedural hemoglobin drop ≥ 1 g/dl was identified in 41% (400/972) of PCI and in 49% (213/435) of PVI. More than one access site predicted a higher risk of a subclinical drop in hemoglobin in both groups. A body mass index ≥ 30 predicted a lower risk of a subclinical drop in hemoglobin in both groups. For PCI, creatinine clearance < 60 ml/min was associated with a higher risk of a subclinical drop in hemoglobin. In conclusion, clinically silent peri-procedural hemoglobin fall ≥ 1 g/dl is common in patients undergoing both coronary and peripheral percutaneous intervention. Predictors identified in our study will need prospective validation.
Subject(s)
Angioplasty, Balloon, Coronary/adverse effects , Coronary Artery Disease/therapy , Hemoglobins/metabolism , Peripheral Arterial Disease/therapy , Postoperative Hemorrhage/etiology , Aged , Body Mass Index , Cohort Studies , Coronary Artery Disease/blood , Creatinine/metabolism , Female , Humans , Kidney Failure, Chronic/metabolism , Male , Middle Aged , Peripheral Arterial Disease/blood , Postoperative Hemorrhage/blood , Retrospective Studies , Risk FactorsABSTRACT
Acute limb ischemia is a medical emergency with management options ranging from urgent revascularization to limb amputation. The best patient outcome requires tailoring the treatment to the individual patient. This article describes a step-by-step approach for diagnosis and management of patients presenting with acute limb ischemia.