Use of vascular sealing devices (VasoSeal and Perclose) versus assisted manual compression (Femostop) in transcatheter coronary interventions requiring abciximab (ReoPro).

UNLABELLED: Transcatheter coronary interventions requiring abciximab (ReoPro) are associated with vascular access site complications. Several devices have been developed to aid in the closure of the femoral arteriotomy, including collagen plug devices (VasoSeal, AngioSeal), percutaneous suture closure (Perclose), and aids to manual compression (Femostop). In 185 patients who received abciximab plus aspirin and heparin for transcatheter coronary interventions, we compared femoral arteriotomy closure by three different methods: VasoSeal, Perclose, and Femostop. A composite endpoint of late complications defined as an access site-related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, arterial or venous thrombosis was compared. VasoSeal was initially successful in 41/52 patients (78.8%). The 11 patients who failed to have adequate hemostasis with VasoSeal required manual compression aided by Femostop, but had no late complications. There was one access site infection and one fatal retroperitoneal hematoma unrelated to the vascular access site (surgically explored). There were no late complications. Perclose was successful in 48/56 patients (85.7%). One Perclose failure required surgical repair for an extensive arteriotomy. The other Perclose failure required manual compression aided by Femostop, but had no late complications. There were no access site infections requiring intravenous antibiotics. There was one retroperitoneal bleed that extended the patient's hospital stay and for which a blood transfusion was required. Femostop was successful in 77/77 patients (100%). There were no infections. Late complications occurred in four patients. These included three episodes of bleeding or hematomas requiring blood transfusion, and one pseudoaneurysm. CONCLUSION: In patients receiving abciximab in addition to aspirin and heparin, VasoSeal and Perclose are at least as safe as Femostop when used to achieve homeostasis after sheath removal. VasoSeal and Perclose have a significantly lower initial rate of successful hemostasis than Femostop. The numbers of late complications between the VasoSeal, Perclose, and Femostop groups were not significantly different. In those patients in whom VasoSeal or Perclose failed, no late complications occurred. Access site infections were no different between VasoSeal, Perclose, and Femostop.

Hearing in honey bees: detection of air-particle oscillations.

Although the airborne sounds produced by dancing honey bees seem essential in the bees' dance communication, attempts to show directly that bees can detect airborne sounds have been unsuccessful. It is shown here that bees can in fact detect airborne sounds and that they do so by detecting air-particle movements. Most vertebrates, by contrast, detect pressure oscillations. Because all traveling sound waves have both components, either can be used in sound detection. The bees' acoustic sense appears to be sensitive enough to allow bees to detect the air-particle movements that occur within several millimeters of a sound-emitting dancer.

Erythrocyte survival in patients with porcine xenograft aortic and mitral valves.

Ten patients with porcine xenograft aortic and mitral valve prostheses were studied three to 36 months (mean 15 months) postoperatively for evidence of hemolysis. Studies included complete blood count, reticulocyte count, red cell indices, percentage of schistocytes on blood smears, bilirubin concentration, lactic dehydrogenase, serum iron, total iron binding capacity, haptoglobin, serum folate and vitamin B12 levels, Coombs' test, methemoglobin reduction test, autologous 51Cr erythrocyte survival, and urinary examination for iron and hemosiderin. All patients were hemodynamically stable. Nine patients had normal valve function and no evidence of hemolysis. One patient with paravalvular aortic regurgitation had mechanical hemolytic anemia with a negative Coombs' test. Porcine valve xenografts do not seem to be associated with hemolysis unless complicated by a paravalvular leak.

Primary meningococcal pericarditis.

We have described two patients with primary meningococcal pericarditis. The first patient required open surgical drainage. In the second patient, pericardiectomy was eventually required. Thirteen cases of primary meningococcal pericarditis have now been reported. All the patients survived, in contrast to purulent pericarditis of other causes.

A midsystolic ejection click.

A patient of faintly marfanoid habitus with left venticular failure, aortic regurgitation, and rate-related left bundle-branch block was found to have a midsystolic click and echocardiographic findings suggestive of mitral valve prolapse; however, the click did not move earlier in systole in response to head-up tilt or atrial pacing. Cardiac catheterization and angiocardiographic studies revealed severe left ventricular dysfunction out of proportion to the moderate amount of aortic regurgitation observed on aortographic study. Mitral valve prolapse was not confirmed by left ventriculographic study. Intracardiac phonocardiographic and catheter-tip manometric studies identified the click as being aortic in origin, ejection in timing, and midsystolic, rather than early systolic, because of delayed aortic valve opening related to left ventricular dysfunction and delay in conduction.

The HLA antigens and ABO blood groups in an American Black population with mitral valve prolapse.

A total of 42 American Black patients with mitral valve prolapse and 194 healthy individuals of similar ethnic background were tested for the distribution of various HLA antigens and ABO blood groups. The most significant result was an increased frequency of Bw35 in patients (74%) as compared with controls (39%), with a P value of less than 0.0001; the relative risk was 4.45.

Clinical limitations of the Low Back Scale.

Administered the Low Back (Lb) Scale, a special derivative of the MMPI, to 20 patients with functional low back pain and 20 patients with verifiable organic evidence for their low back complaints. The Social Desirability Scale also was administered in order to assess the test-taking attitudes of the patients. The two groups of patients were equated in terms of age and sex. The results revealed no significant differences between the functional and organic patients in scores on the Lb Scale and on the Social Desirability Scale. The findings, which were consistent with other recent studies of the Lb Scale, strongly suggested that the clinical usefulness of this scale is highly questionable.

Differentiation of posterior myocardial infarction from right ventricular hypertrophy and normal anterior loop by echocardiography.

The differentiation of posterobasal myocardial infarction (PMI) from either right ventricular hypertrophy (RVH) or normal subjects displaying an anterior loop (AL) by electrocardiography (ECG) or vectorcardiography (VCG) is difficult. M-mode echocardiography (echo) via the anterior and subxiphoid methods has been helpful in defining cardiac chamber size and wall motion abnormalities. We tested whether this relatively more direct method would better separate these entities compared with the other two techniques. ECG and VCG using established criteria failed to distinguish the three conditions effectively. By echo, distinguishing characteristics were observed in each of the groups. Thus, right ventricular diastolic dimension and wall thickness were significantly increased only in the RVH group, echo dimensions and wall motion were normal in the AL group and the posterior left ventricular systolic thickening response and ejection phase indices were significantly reduced only by the subxiphoid method in the PMI group. To test the specificity of the latter finding, posterior wall motion in three infarction groups (posterior, combined posteroinferior and inferior) were examined and suggested that the target of the subxiphoid beam focuses on a more superior posterobasal left ventricular segment than the anteriorly placed transducer. Echocardiography can differentiate PMI from either RVH or AL more directly than ECG or VCG, and may be of practical clinical importance.

A new method for measurement of sinoatrial conduction time.

This study describes a new method (NM) for estimation of sinoatrial conduction time (SACT), which utilizes constant atrial pacing (AP) instead of the premature atrial beats (PABs) used in the method reported in 1973 by Strauss et al. The SACTs were obtained by both methods in 20 patients. The SACT by the Strauss method (SM) was calculated as A2A3 minus A1A1. The NM consists of high right AP for a train of eight consecutive beats at rates less than or equal to 10 beats/min faster than the sinus rhythm. The interval between the last paced atrial electrogram (Ap) and the first escape atrial electrogram (A) of sinus origin (Ap-A) was measured along with several post pacing sinus cycles. The SACT by the NM was calculated as follows: SACT = Ap-A minus A1A1. The effect of AP at higher rates was also analyzed. In two patients, the SACT with the SM could not be defined, as all the A2A3 intervals were fully compensatory; with the NM the SACT was 217 and 320 msec. In the remaining 18 patients the SACT was obtainable by both methods. With SM, the SACT ranged 105--452 msec (mean 219 +/- 102 SD) and with the NM it was 85--492 msec (mean 201 +/- 112 SD), and the difference was statistically significant (P = 0.0162). The coefficient of correlation between the two methods was r = 0.97. During AP at faster rates, a rate related increment in Ap-A intervals and also post pacing sinus cycles was noted. This study describes a new and simple method for measurement of SACT in man.

Infective aneurysm of the left ventricle: angiographic and echocardiographic features.

A 17-year-old man with staphylococcal endocarditis of the mitral valve developed an infective aneurysm of the posterior left ventricular wall. Echocardiography revealed an echo-free space posterior to the posterior left ventricular wall. This echo-free space undoubtedly represented the aneurysmal sac, because it could be temporarily obliterated by injecting saline into it and was no longer detectable following surgical closure of the sac. Thus echocardiography may be helpful in the detection of an infective aneurysm of the left ventricle.

Echocardiographic assessment of ventricular performance following induction with two anesthetics.

Echocardiographic studies were made of 20 healthy patients scheduled for minor surgical procedures to determine whether this technique could be used routinely in the operating room and to evaluate the effects of halothane and enflurane on left ventricular performance. Thirteen minutes following induction of anesthesia with halothane in ten patients (mean end-tidal halothane concentration 0.93 per cent), mean arterial blood pressure, left ventricular (LV) diastolic dimension, LV fractional shortening, mean velocity of circumferential fiber shortening and systolic thickening of the posterior LV wall were significantly decreased. LV systolic dimension was increased significantly. These data indicate that halothane caused decreased contractility in the presence of a decreased afterload. Twelve minutes following induction of anesthesia with enflurane in ten patients (mean delivered enflurane concentration 2.4 per cent), mean arterial blood pressure and LV systolic and diastolic dimensions were decreased, while heart rate was increased significantly, indicating that enflurane caused vasodilatation and may have had some depressant effect on contractility. Echocardiography is a non-invasive, safe and relatively rapid method that can be used in the perioperative period to assess cardiac function and to evaluate the effects of pharmacologic agents on the heart.

Effects of gravitational stresses on mitral valve prolapse. I. Changes in auscultatory findings produced by progressive passive head-up tilt.

The effects of passive head-up tilt on systolic time intervals were assessed in 18 patients with mitral valve prolapse. In addition to causing prolongation of the pre-ejection period and shortening of left ventricular ejection time, this circulatory stress led to progressive shortening of the Q to click interval. In 1 patient, a systolic click became audible which had not been heard in the supine posture. In 7 patients the click disappeared during head-up tilt, usually at 60 degrees or 90 degrees. In 2 patients without a murmur while supine, a mid-late systolic murmur appeared with tilt; 1 of these 2 as well as another patient who had a soft late systolic murmur while supine developed loud systolic whoops at greater angles of tile. The correlations between Q to click interval and aortic valve opening to click interval, and both the angle and the sine of the angle of tilt were highly significant.

Tuberculous Addison's disease and thyrotoxicosis.

Addison's disease developed in two patients after they had tuberculosis. Thyrotoxicosis subsequently developed. In both cases, the adrenal glands were calcified, suggesting that Addison's disease was tuberculous in origin. Results of tests for antihyroglobulin, antimicrosomal, and adrenal cortex antibodies were normal. These findings do not suggest an autoimmune basis for the occurrence of the two endocrinopathies. The rarity of the simultaneous occurrence of both disorders suggests it to be fortuitous.

Electrocardiographic changes simulating acute myocardial infarction caused by hyperkalemia: report of a patient with normal coronary arteriograms.

A patient is described with severe diabetic ketoacidosis and hyperkalemia who presented with an ECG resembling an acute anterior wall myocardial infarction. Treatment of hyperkalemia resulted in prompt return of the ECG towards normal. Subsequent work-up including exercise testing and selective coronary arteriography ruled out any significant coronary artery disease suggesting that the ECG changes were probably caused by hyperkalemia. While similar changes have rarely been described in the past, this would appear to be the first such case in whom coronary artery disease was ruled out by a negative exercise testing and coronary arteriography.

The mitral knock with atrial fibrillation. A possible source of auscultatory confusion.

A 29-year-old woman with atrial fibrillation and severe rheumatic mitral regurgitation initially had a very loud third heart sound with high-frequency components (mitral knock), as well as with a first heart sound of widely varying intensity. After long diastoles a faint first heart sound was heard, with distinct separation from the third heart sound of the preceding cycle; however, on short cycles the loud and high-pitched third heart sound combined with a loud first heart sound to simulate the combination of a first heart sound with an ejection click. Phonoechocardiographic studies clarified the identity of the transients.