Vitamin D deficiency and functional response to CRT in heart failure patients.

BACKGROUND: Vitamin D deficiency has been associated with a poor outcome in patients with heart failure (HF). We examined the role of vitamin D in the response of HF patients to cardiac resynchronization therapy (CRT). METHODS: The study comprised 50 patients (30 men and 20 women) with HF undergoing CRT implantation who were prospectively enrolled. Response to CRT was defined as a combination of ≥15% reduction in left ventricular end-systolic volume (LVESV) and ≥10% improvement in the 6­Minute Walk Test within 6 months. Patients were grouped based on their levels of vitamin D prior to CRT implantation. Clinical and echocardiographic examinations were performed prior to and 6 months after the procedure. RESULTS: Of the patients, 11 (22%) failed to respond to CRT; two patients died within 6 months and an additional nine patients showed no improvement in the 6­Minute Walk Test and no reduction in their baseline LVESV. A comparison was made between 25 patients with sufficient levels of vitamin D and 25 patients with insufficient levels. Nine patients (36%) in the "insufficient" group and two patients (8%) in the "sufficient" group failed to respond to CRT implantation (p = 0.037). CONCLUSION: Adequate serum concentrations of vitamin D play a significant role in improving the functional status of patients with systolic HF following CRT implantation.

Effect of remote ischemic postconditioning during thrombolysis in STEMI.

BACKGROUND: Remote ischemic postconditioning (RIPC) is suggested to protect the myocardium against ischemia in various settings. However, the effect of RIPC in patients with acute ST-elevation myocardial infarction (STEMI) who undergo thrombolysis has yet to be examined. PATIENTS AND METHODS: In this single-center, randomized controlled trial, we examined the effect of RIPC on the resolution of ST-segment elevation (STR) in response to thrombolysis. Patients in the RIPC group had three cycles of 5­min cuff inflation followed by 5­min deflation to the upper arm. RESULTS: The study comprised 78 patients (15 women), of whom 41 were randomized to the RIPC group and 37 to the control group. STR occurred in 61% of the patients in the RIPC group, while it was detected only in 35% of controls (p = 0.026). Although STR was more common in the RIPC group, there was no difference in the extent of ΣCK-48 h between the two groups. Furthermore, the length of hospital stay and the frequency of adverse events were similar between the RIPC and control groups. CONCLUSION: RIPC during thrombolytic therapy in STEMI was associated with a higher frequency of STR. However, it did not affect enzymatic infarct size or the frequency of adverse events. (Clinical trial registration number: IRCT2014011916229N2.).

Operator radiation exposure during transradial coronary angiography : Effect of single vs. double catheters.

BACKGROUND: The right radial artery has gained popularity as the preferred access site for coronary angiography. To save time and limit the radiation exposure of operators and patients, newly designed catheters can be used to access both the right and left coronary arteries. The aim of this study was to compare operator radiation exposure between single-catheter (SCA) and two-catheter approaches (TCA). METHODS: In all, 256 patients undergoing diagnostic coronary angiography via the right radial artery in a high-volume medical center were randomized to either the SCA or TCA group. The dose of radiation exposure of the operators was measured by an electronic dosimeter attached to the breast pocket of the operator's apron. The dose-area product and air kerma were used as indices of patient exposure to radiation. The duration of fluoroscopy "beam-on" time, acquisition time, and total duration of the procedure were measured and analyzed for the two groups. RESULTS: Operator radiation exposure was 21.6 ± 11.4 µSv in the SCA group, which was significantly less than 28.0 ± 14.9 µSv in the TCA group. The duration of fluoroscopy was significantly shorter in the SCA group than in the TCA group (152 ± 83 vs. 203 ± 121 s; p < 0.001). Moreover, the total duration of the diagnostic procedure was also shorter in the SCA group compared with the TCA group (9.5 ± 3.2 vs. 11.4 ± 4.0 min; p < 0.001). CONCLUSION: The use of SCA is advantageous over TCA in reducing the exposure of operators to radiation. The shorter duration of fluoroscopy beam-on time and total procedure time may contribute to the lower exposure of operators to radiation.

Predicting outcome after percutaneous balloon mitral commissurotomy : Role of neutrophil-lymphocyte ratio.

BACKGROUND: The value of the neutrophil-lymphocyte ratio (NLR) along with the severity of mitral stenosis (MS) in predicting the outcome of percutaneous balloon mitral commissurotomy (PBMC) has not been studied. PATIENTS AND METHODS: Patients with severe MS undergoing PBMC between 2013 and 2014 in a university hospital were prospectively enrolled. Complete blood cell count was obtained upon admission and NLRs were calculated. The correlations between NLR with immediate PBMC success and restenosis in 1 year were evaluated. RESULTS: In all, 102 patients (80 women) with a mean age of 44.5 ± 13.1 years were enrolled in the study. NLR on admission was 2.6 ± 0.8 and mitral valve area (MVA) was 0.89 ± 0.18 cm2. Patients with a lower MVA at baseline had a higher NLR (p = 0.016). The rate of immediate success was 63 % for PBMC. There was no difference in NLR between patients with regard to early and late failures, as well as those who developed restenosis of the valve. Smaller valve area and the rate of valvular dilatation during PBMC were the only independent factors that predicted early and late failure, respectively. CONCLUSION: NLR at the time of treatment was not useful in predicting procedural outcome or restenosis during follow-up of patients undergoing PBMC.

Pulmonary hypertension in rheumatic mitral stenosis revisited.

BACKGROUND: In patients with mitral stenosis (MS), pulmonary hypertension (PH) is a significant contributor to the associated morbidity. We aimed to study factors associated with the presence of significant PH (sPH) and whether incorporating body surface area (BSA) in the mitral valve area (MVA) would improve the predictive value of the latter. METHODS: The medical records of 558 patients with severe MS undergoing percutaneous balloon mitral commissurotomy were evaluated over a period of 8 years. Factors associated with the presence of significant PH (sPH) defined as mPAP ≥ 40 mm Hg were examined. RESULTS: A total of 558 patients (423 women) were enrolled. Overall, 153 (27%) patients had sPH. Patients with sPH were similar to the rest of the subjects in terms of demographics, body habitus, blood group, and incidence of atrial fibrillation. Among echocardiographic findings, absolute MVA, indexed MVA, and mean transmitral valve gradient were associated with the presence of sPH. Transmitral valve gradient during right heart catheterization had the highest area under the curve for an association with sPH. CONCLUSION: Age, gender, heart rhythm, and blood group were not associated with the presence of sPH in severe MS. The predictive value of the indexed MVA for the presence of sPH was not higher than that of absolute MVA.

Association of ABO blood types with the risk of in-stent restenosis.

OBJECTIVES: To investigate the prevalence of in-stent restenosis (ISR) in patients with various ABO blood types. METHODS: Clinical information from 150 patients with a confirmed diagnosis of ISR and 150 patients with a diagnosis of patent coronary stents in the secondary angiography was collected. Comprehensive demographic and laboratory data, including ABO and Rhesus blood groups, as well as comorbid conditions and vessel and stent characteristics, were recorded for each patient. The association of ABO blood groups with the risk of ISR before and after controlling for coronary risk factors was determined. Categorical data were analyzed with the Chi-square test and numerical values were analyzed with t-tests. Binary logistic regression models were constructed to compare type A and non-A for the frequency of risk factors. RESULTS: A total of 392 stents were implanted in 300 patients. Two hundred and fourteen stents (54.6%) were patent and 178 stents (45.4%) were stenosed. Blood group A was significantly more common in the ISR group (43.3% vs. 28.7%, p=0.03). However, the frequencies of other blood types, as well as Rh antigen, were similar between the two groups. Triglyceride and low-density lipoproteins were the only significantly different variables (221 ± 198 mg/dL vs. 138 ± 76 mg/dL, p<0.001 and 108 ± 36 mg/dL vs. 96 ± 73 mg/dL, p=0.04, in type-A vs. non-A, respectively). After matching for coronary risk factors, there was no difference between A blood type patients and their controls. CONCLUSION: ISR is significantly more prevalent in individuals with the type A blood group. However, this higher association is most likely due to higher atherogenic conditions in patients within this population.

Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery.

INTRODUCTION: The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients. METHODS: Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome. RESULTS: Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05). CONCLUSIONS: Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.

Biatrial pacing vs. intravenous amiodarone in prevention of atrial fibrillation after coronary artery bypass surgery.

This study was aimed to compare the results of post operative biatrial pacing and i.v. amiodarone in prevention of AF. In a single blind randomized clinical trial, 210 patients scheduled for elective CABG surgery were randomized either to receive overdrive biatrial pacing, i.v. amiodarone or no intervention. Incidence of AF postoperatively evaluated. Pacing was successful in 83% of patients and 80% of patients in amiodarone group could receive their drug. Twenty and one patients developed AF. Incidence of AF in pace, amiodarone and control group was 10.7, 5.3 and 17.9%, respectively (p = 0.08). Comparing incidence of AF between pacing and control group, the difference was not significant (p = 0.2), but the difference between amiodarone and control groups was significant statistically (p = 0.03). Patients who developed AF were older but their left ventricular ejection fraction was not different with patients without AF. The ICU stay was higher in patients with AF. Use of i.v. amiodarone was more effective than biatrial pacing in prevention of post operative AF and we recommend use of this drug in high risk patients.