Left atrial appendage closure with amplatzer septal occluder in patients with atrial fibrillation: CT-based morphologic considerations.

OBJECTIVES: This study analyzed left atrial appendage (LAA) dimensions measured by computed tomography (CT) scan to define optimal selection of Amplatzer septal occluders for LAA closure. BACKGROUND: Patients with atrial fibrillation and contraindications to anticoagulation have limited options for LAA closure until approval of dedicated closure devices. Off-label use of available cardiac devices represents one option. METHODS: All consecutive patients undergoing LAA occlusion with an Amplatzer device who had undergone CT scanning were included. Numerous dimensions of the LAA were measured in order to optimally select a device that would simultaneously provide good anchoring and good sealing of the LAA. RESULTS: Of 11 eligible patients, 8 had successful Amplatzer deployment. In all successful cases, the putative "left atrial" disc was well matched to the "landing zone" of the LAA, proving good anchoring. The proximal (putative "right atrial") disc was sized to cover the LAA orifice. The failed cases shed light on procedural variables. CONCLUSIONS: LAA occlusion with an Amplatzer device is a viable option for patients with atrial fibrillation and contraindications to anticoagulation. Careful attention to LAA dimensions as measured on CT scan assists in optimizing device selection.

Assessment of a novel software tool in the selection of aortic valve prosthesis size for transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) can be complicated by significant paravalvular leak (PVL). Optimal selection of TAVR prosthesis size can minimize the risk of clinically significant PVL. The aim of this study was to assess the utility of a proprietary software package, HeartNavigator (Philips), in selecting TAVR prosthesis to minimize PVL. METHODS: All consecutive TAVR patients were considered for inclusion. HeartNavigator assessment was compared to three conventional (average, area-based, and circumference- based) computed tomography (CT) scan measurements of annulus diameter. The primary endpoint was clinically important (≥2+) aortic insufficiency (AI). RESULTS: Fifty-six patients were suitable for analysis. The incidence of clinically important AI was 25%. The overall predictive value was identical for HeartNavigator (80.4%) and the three conventional CT parameters. Each method correctly identified a majority of patients destined for AI. Although HeartNavigator accurately identified a numerically greater portion of patients with AI (64.3%), this was not significantly different from the conventional CT parameters. CONCLUSIONS: As compared to conventional CT-based measurements, HeartNavigator offers an accurate method for selecting TAVR prostheses, comparable to conventional CT measurements.

Pharmacodynamic evaluation of switching from ticagrelor to prasugrel in patients with stable coronary artery disease: Results of the SWAP-2 Study (Switching Anti Platelet-2).

OBJECTIVES: The goal of this study was to evaluate the pharmacodynamic effects of switching patients from ticagrelor to prasugrel. BACKGROUND: Clinicians may need to switch between more potent P2Y12 inhibitors because of adverse effects or switch to the use of a once-daily dosing regimen due to compliance issues. METHODS: After a 3- to 5-day run-in phase with a ticagrelor 180-mg loading dose (LD) followed by a ticagrelor 90-mg twice-daily maintenance dose (MD), aspirin-treated patients (N = 110) with stable coronary artery disease were randomized to continue ticagrelor or switch to prasugrel 10-mg once-daily MD, with or without a 60-mg LD. Pharmacodynamic assessments were defined according to P2Y12 reaction unit (PRU) (P2Y12 assay) and platelet reactivity index (vasodilator-stimulated phosphoprotein phosphorylation assay) at baseline (before and after the run-in phase) and 2, 4, 24, and 48 h and 7 days after randomization. RESULTS: Platelet reactivity was significantly greater at 24 and 48 h after switching to prasugrel versus continued therapy with ticagrelor, although to a lesser extent in those receiving an LD. Mean PRU remained significantly higher in the combined prasugrel groups versus the ticagrelor group (least-squares mean difference: 46 [95% confidence interval 25 to 67]) and did not meet the primary noninferiority endpoint (upper limit of the confidence interval ≤45), although PRU in the prasugrel cohort was lower at 7 days than at 24 or 48 h. Accordingly, rates of high on-treatment platelet reactivity were higher at 24 and 48 h in both prasugrel groups. At 7 days, there was no difference in high on-treatment platelet reactivity rate between the combined prasugrel and ticagrelor groups. CONCLUSIONS: Compared with continued ticagrelor therapy, switching from ticagrelor to prasugrel therapy was associated with an increase in platelet reactivity that was partially mitigated by the administration of an LD.

Failure of surgical and endovascular infrainguinal and iliac procedures in the management of peripheral arterial disease using data from electronic medical records.

PURPOSE: To understand rates of procedure failure among patients undergoing revascularization for peripheral arterial disease (PAD) in clinical practice. MATERIALS AND METHODS: This retrospective analysis of patients with PAD who underwent a PAD-related procedure used claims and electronic medical record data from 2005 to 2009. Procedures were grouped by type (endovascular [ie, angioplasty with/without stent, atherectomy] or surgical [ie, bypass surgery, endarterectomy, thrombectomy]) and site (ie, iliac, infrainguinal). The study assessed antiplatelet and anticoagulant agent use; procedure failure, defined as a subsequent procedure or amputation; and predictors of time to procedure failure. RESULTS: A sample of 248 patients with PAD who underwent a PAD-related procedure was identified. The population was 59% male, had a mean age of 73 years, and had a mean follow-up of 23 months. Endovascular procedures alone were performed in 37% of patients, with the remainder receiving surgery only or surgery with an endovascular procedure, and 79% of patients had an infrainguinal intervention. Antiplatelet and anticoagulant use rates after the procedure were 90% and 25%, respectively. After their initial procedure, 20% of patients required a second procedure or amputation, with an average failure time of 228 days. Patients treated with infrainguinal procedures had a significantly higher failure rate versus those treated with iliac procedures (23% vs 8%; P = .011). In multivariate analysis, patients without anticoagulant use before the procedure were at significantly lower failure risk (P = .022). CONCLUSIONS: Repeated intervention and/or major amputation after revascularization of PAD was common. Further investigation of the factors associated with procedure failure is warranted.

Markers of cardiac collagen turnover are similar in patients with mild and more severe symptoms of heart failure.

Cardiac fibrosis plays an important role in the pathophysiology of heart failure. The authors sought to determine whether biomarkers of cardiac fibrosis for milder clinical degrees of heart failure are comparable to those of more advanced disease. Procollagen types I and III amino-terminal peptides (PINP and PIIINP) and type I collagen telopeptide (ICTP) were compared between aldosterone-antagonistnaive patients with heart failure and New York Heart Association class I or II (n=22/23) and class III or IV (n=42/3) symptoms. Median (interquartile) range concentrations of PINP (63.3 [44.2-88.8] vs 48.6 [37.8-74.9] microg/L), ICTP (7.0 [5.4-16.8] vs 6.5 [4.7-12.7] microg/L), and PIIINP (4.7 [3.2-7.0] vs 4.7 [2.9-7.3] microg/L) were comparable between patients with mild and moderate to severe disease, respectively. These data suggest that patients with mild heart failure may have similar degrees of cardiac fibrosis to patients with more severe disease and support the examination of antifibrotic therapy, including aldosterone antagonists, in milder degrees of heart failure.

Outcome of heart transplantation in patients with sarcoid cardiomyopathy.

BACKGROUND: Cardiac transplantation has been utilized increasingly in patients with sarcoid cardiomyopathy. We sought to review outcomes in patients with sarcoidosis who had heart transplants and compared their outcomes with those of transplanted patients without sarcoidosis. METHODS: We retrospectively reviewed the United Network for Organ Sharing (UNOS) database to assess the survival of patients with sarcoidosis who were treated by heart transplantation. RESULTS: Over an 18-year period, 65 patients (40 men and 25 women) with sarcoidosis underwent orthotopic heart transplantation. There were 4 operative deaths and 12 late deaths at a mean follow-up of 40 months. One-year post-transplant survival was significantly better for sarcoid patients receiving orthotopic transplantation compared with contemporaneous patients receiving transplantation for all other diagnoses (87.7% vs 84.5%, p = 0.030). CONCLUSIONS: Patients with sarcoidosis undergoing orthotopic heart transplant had better short- and intermediate-term survival than the majority of heart transplant recipients. The diagnosis of sarcoidosis should not disqualify potential transplant candidates.

Thromboprophylaxis with dalteparin in medical patients: which patients benefit?

It is unclear whether thromboprophylaxis produces a consistent risk reduction in different subgroups of medical patients at risk from venous thromboembolism. We performed a retrospective, post hoc analysis of 3706 patients enrolled in the PREVENT study. Patients were at least 40 years old with an acute medical condition requiring hospitalization for at least 4 days and had no more than 3 days of immobilization prior to enrolment. Patients received either subcutaneous dalteparin (5000 IU) or placebo once daily. The primary end point was the composite of symptomatic deep vein thrombosis (DVT), pulmonary embolism, asymptomatic proximal DVT, or sudden death. Primary diagnosis subgroups were acute congestive heart failure, acute respiratory failure, infectious disease, rheumatological disorders, or inflammatory bowel disease. All patients, except those with congestive heart or respiratory failure, had at least one additional risk factor for venous thromboembolism. A risk reduction was shown in patients receiving dalteparin versus placebo. The relative risk (RR) was 0.73 in patients with congestive heart failure, 0.72 for respiratory failure, 0.46 for infectious disease, and 0.97 for rheumatological disorders. The RR was 0.52 in patients aged > or = 75 years, 0.64 in obese patients, 0.34 for patients with varicose veins, and 0.71 in patients with chronic heart failure. No subgroup had a significantly different response from any other. Importantly, multivariate analysis showed that all patient groups benefited from thromboprophylaxis with dalteparin. Our findings, therefore, support the broad application of thromboprophylaxis in acutely ill hospitalized medical patients.

N-acetylcysteine in the prevention of contrast-induced nephropathy: publication bias perpetuated by meta-analyses.

BACKGROUND: The use of N-acetylcysteine for the prevention of contrast-induced nephropathy has been the subject of numerous clinical trials and meta-analyses. We sought to examine the possibility of a publication bias and whether meta-analyses have magnified any potential publication bias. METHODS: We performed a Medline search and a manual search to identify published manuscripts. We also manually searched contemporaneous major cardiology scientific meetings to identify abstracts. We included only randomized controlled clinical trials. We pooled the results of abstracts and manuscripts separately and combined, calculating an odds ratio (OR). We analyzed meta-analyses according to the proportions of manuscripts and abstracts that they included and compared their calculated ORs to the OR of all available contemporaneous data. Our analysis spanned the time from the publication of the first manuscript on this topic through June 2006. RESULTS: Throughout the study period, the published manuscripts presented a treatment-effect estimate that was more optimistic than that found in unpublished abstracts. There was a temporal trend in that the estimate of treatment effect was greatest with early publications, which diminished as additional data became available. The profile of the journal (as assessed by impact factor) in which a manuscript was published was not related to the quality of the manuscript. However, studies reaching a positive conclusion were published in journals with higher impact factors compared with studies reaching negative conclusions. Meta-analyses included a substantially greater proportion of published manuscripts versus unpublished abstracts and provided more optimistic assessments of treatment effect than would have been derived had all available data been assessed. CONCLUSIONS: There was a significant publication bias that persisted throughout the life cycle of this clinical question. The bias was further amplified by meta-analyses.

Racial differences in potassium response to spironolactone in heart failure.

Evidence of racial differences in aldosterone concentrations and K+ disposition suggests that response to aldosterone antagonism might vary by race. The authors sought to determine whether K+ response to spironolactone differs between African Americans and Caucasians with heart failure. Heart failure patients of African-American (n = 34) or Caucasian (n = 17) race were started on spironolactone 12.5 mg/d, with up-titration as tolerated. Laboratory values and drug therapy were similar between racial groups at baseline. Spironolactone was titrated to a median dose of 25 mg/d in both groups. Neither concomitant medications nor serum creatinine changed significantly in either group during spironolactone dose titration. Median serum K+ concentrations increased by 0.5 mEq/L (range, -0.7 to 1.6 mEq/L) in Caucasians, but only 0.1 mEq/L (range, -0.8 to 0.9 mEq/L) in African Americans; p < 0.01. These data suggest that African Americans with heart failure may be less responsive to the renal effects of spironolactone.

Unrecognized stent embolization causing recurrent chest pain.

Numerous methods have been described for retrieving or addressing stents that have embolized in the coronary arteries. Almost all of these prior reports address the "freshly" embolized stent with retrieval or deployment occurring during the same index procedure during which the embolization occurred. We describe a case of a thrombosed, chronically embolized coronary stent.

Risks of noncardiac surgery after coronary stenting.

An increased risk of major complications for noncardiac surgery after coronary stenting has been suggested. We retrospectively reviewed all cases of coronary stents from 1999 to 2003 with subsequent surgery to assess major adverse cardiovascular events (MACEs), including myocardial infarction, stent thrombosis, major bleeding, and death. Among the 56 patients identified, 8 developed MACEs; 38% underwent surgery < or =14 days after stenting, and 62% underwent surgery 15 to 42 days after stenting. No patient developed MACEs if surgery occurred >42 days after stenting. Among patients who developed MACEs, 77% of surgeries were elective, 19% were urgent, and only 4% were emergency. Noncardiac surgery 6 weeks after coronary stenting is associated with a high risk of MACEs.

Efficacy and safety of fixed low-dose dalteparin in preventing venous thromboembolism among obese or elderly hospitalized patients: a subgroup analysis of the PREVENT trial.

BACKGROUND: We were concerned that a fixed rather than a weight-based dosing regimen of dalteparin sodium to prevent venous thromboembolism (VTE) might result in decreased efficacy in obese patients and decreased safety in elderly patients. METHODS: We retrospectively performed subgroup analyses using the database from the Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilized Patients (PREVENT) Trial, a study of 3706 hospitalized, medically ill patients randomized to receive either dalteparin sodium, 5000 U/d, or placebo. The primary end point was a composite of symptomatic VTE, fatal pulmonary embolism, sudden death, or asymptomatic proximal deep venous thrombosis by day 21. Obesity was defined as a body mass index (calculated as weight in kilograms divided by the square of height in meters) of 30 or greater for men and 28.6 or greater for women. RESULTS: Overall, 1118 patients (30.4%) were obese and 1226 (33.3%) were 75 years or older. In obese patients, the primary end point occurred in 2.8% of the dalteparin and in 4.3% of the placebo groups (relative risk, 0.64; 95% confidence interval [CI], 0.32-1.28). In patients 75 years or older, the primary end point was reported in 4.2% of the dalteparin and in 8.0% of the placebo groups (relative risk, 0.52; 95% CI, 0.31-0.87). The dalteparin effect for the primary end point (odds ratio, 0.51; 95% CI, 0.32-0.82) was not attenuated when adjusted for age, sex, obesity, history of VTE, and varicose veins. Dalteparin was not associated with an increase in major hemorrhage by day 21 in obese (0% vs 0.7% placebo; P>.99) and in elderly (1.1% vs 0.7%; P=.12) patients. CONCLUSION: Our findings suggest that a fixed low dose of dalteparin sodium of 5000 U/d is effective and safe in preventing VTE in obese and elderly hospitalized medical patients.

Mortality rates and risk factors for asymptomatic deep vein thrombosis in medical patients.

The clinical importance of asymptomatic proximal and distal deep vein thrombosis (DVT) remains uncertain and controversial. The aim of this retrospective, post-hoc analysis was to examine mortality and risk factors for development of proximal DVT in hospitalized patients with acute medical illness who were recruited into a randomized, prospective clinical trial of thromboprophylaxis with dalteparin (PREVENT). We analyzed 1738 patients who had not sustained a symptomatic venous thromboembolic event by Day 21 and who had a complete compression ultrasound of the proximal and distal leg veins on Day 21. We examined the 90-day mortality rates in patients with asymptomatic proximal DVT (Group I, N=80), asymptomatic distal DVT (Group II, N=118) or no DVT (Group III, N=1540). The 90-day mortality rates were 13.75%, 3.39%, and 1.92% for Groups I-III, respectively. The difference in mortality between Group I and Group III was significant (hazard ratio 7.63, 95% CI=3.8-15.3; p <0.0001), whereas the difference between Groups II and III did not reach significance (hazard ratio 1.36, 95% CI=0.41-4.45). The association of asymptomatic proximal DVT with increased mortality remained highly significant after adjusting for differences in baseline demographics and clinical variables. Risk factors significantly associated with the development of proximal DVT included advanced age (p=0.0005), prior DVT (p=0.001), and varicose veins (p=0.04). In conclusion, the high mortality rate in patients with asymptomatic proximal DVT underscores its clinical relevance and supports targeting of asymptomatic proximal DVT as an appropriate endpoint in clinical trials of thromboprophylaxis.