Combined percutaneous coronary intervention and atrial septal defect closure in an adult patient.

A case of combined percutaneous coronary intervention and ostium secundum atrial septal defect closure in an elderly patient is reported. The procedure was successful and uneventful. The report demonstrates feasibility of combined percutaneous revascularization and intra- atrial shunt closure even in advanced age.

Statins and the acute coronary syndrome: 'the early bird catches the worm'.

The early period following an acute coronary syndrome (ACS) is characterised by atherosclerotic plaque destabilisation and a pro-coagulant state, and is when patients are at highest risk for recurrent cardiovascular events and mortality. Statins decrease thrombus formation and increase fibrinolysis, inhibit platelet reactivity and aggregation, improve endothelial function in patients with coronary artery disease and have a major role in plaque stabilisation. Several studies showed that initiation of early statin therapy in these settings may have beneficial effects. This review summarises the current data on statins in the setting of ACSs. Known and other possible mechanisms of action are described. The pathophysiological mechanisms, histological features and biochemical characteristics of ACS are different than those with stable coronary disease, thereby suggesting that the mechanisms whereby statins exert their benefits in ACS may be distinct from those for stable CHD. Initiation of the therapy during hospitalisation rather than at the time of hospital discharge may provide protection against early recurrent cardiovascular events and also improve patients' compliance.

Scipione Riva-Rocci and the men behind the mercury sphygmomanometer.

The history of the blood pressure (BP) concept and measurements is described. Many scientists were involved. Among them, major triumphs were achieved by William Harvey during the early 1600s who announced that there is a finite amount of blood that circulated the body in one direction only. In the mid-1700s, Reverend Stephen Hales reported the first invasive measurement in horses and smaller animals. Poiseuille introduced in the early 1800s the mercury hydrodynometer and the mmHg units. Karl von-Vierordt described in 1855 that with enough pressure, the arterial pulse could be obliterated. He also created the sphygmograph, a pulse recorder usable for routine non-invasive monitoring on humans. In 1881, von Basch created the sphygmomanometer and the first non-invasive BP measurements. However, in 1896, Scipione Riva-Rocci developed further the mercury sphygmomanometer, almost as we know it today. The sphygmomanometer could only be used to determine the systolic BP. Observing the pulse disappearance via palpitation would only allow the measuring physician to observe the point when the artery was fully constricted. Nikolai Korotkoff was the first to observe the sounds made by the constriction of the artery in 1905.

Cardiac magnetic resonance imaging in a patient with implantable cardioverter-defibrillator.

The presence of pacemakers and implantable cardioverter-defibrillators (ICD) is considered historically a contraindication to magnetic resonance (MR) imaging. This image modality has unparalleled soft-tissue imaging capabilities, and many consider it as the image of choice for patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). ICDs are now smaller, with less magnetic materials and improved electromagnetic interference protection. We tested modern ICDs for heat, force, function and image distortion and found that several of them may indeed be MRI safe. We report here a patient who was suspected of ARVD/C, underwent ICD implantation based on MR safety testing, and underwent intentionally scheduled follow-up cardiac MR imaging. This is the description of a patient with an ICD who had planned MRI scanning. The scan was safe and most of the MRI images were of high quality.

Haptoglobin phenotype as a predictor of restenosis after percutaneous transluminal coronary angioplasty.

We have demonstrated that a genetic polymorphism in the antioxidant protein haptoglobin is important in determining which patients develop restenosis after percutaneous transluminal coronary angioplasty. Knowledge of the haptoglobin phenotype may be useful in the assessment and utilization of new therapies to reduce restenosis, particularly in patients who are homozygous for the haptoglobin 2 allele.

[Pacing mode influence on morbidity and mortality].

It is widely believed that physiologic pacing (defined as atrial or atrioventricular synchronous pacing) reduces cardiac morbidity and mortality and is associated with improved quality of life compared to ventricular pacing. In this review we present data from three large prospective trials (PASE, CTOPP, MOST) comparing physiologic pacing to ventricular pacing. The prospective trials report that physiologic pacing is associated with a reduced risk of developing chronic atrial fibrillation over time and improved quality of life in patients with sinus node disease compared to ventricular pacing. However, these trials failed to demonstrate that physiologic pacing reduces heart failure, thromboembolism, or cardiac death compared to ventricular pacing. Based on the available clinical trials, physiologic pacing is not indicated in patients with a short life expectancy. Physiologic pacing should be considered for younger patients (age < 75 years), patients likely to be pacemaker dependent, and patients for whom maintenance of sinus rhythm is desirable, i.e., patients with ventricular hypertrophy and diastolic dysfunction who are most likely to be severely symptomatic if AV synchrony is lost.

Long-term prognosis of acute pulmonary oedema--an ominous outcome.

BACKGROUND: Acute pulmonary oedema (APOE) is a major health problem, leading to poor hospital and long-term outcomes. There is a relative paucity of studies describing prognosis of consecutive unsolicited patients diagnosed with APOE and hospitalized in internal medicine departments. AIMS: To describe the clinical profile and outcome (in hospital and 1-year prognosis) of successive unselected patients with APOE, in a prospective observational study. METHODS AND RESULTS: The study population included 150 consecutive unsolicited patients (90 men, 60 women; median age 75 years) with APOE all hospitalized in an internal medicine department, in a 900-bed care centre. Ischaemic heart disease (IHD), hypertension and diabetes were present in 85%, 70% and 52% of patients, respectively. The most common precipitating factors for APOE included high blood pressure (29%), rapid atrial fibrillation (29%), unstable angina pectoris (25%), infection (18%) and acute myocardial infarction (MI; 15%). Eighteen patients (12%) died in hospital, with 82% of these deaths attributed to cardiac pump failure. Predictors for an increased in-hospital mortality included: diabetes (P<0.05), orthopnoea (P<0. 05), echocardiographic finding of depressed global left ventricular systolic function (P<0.001), acute MI during hospital stay (P<0.001), hypotension/shock (P<0.05), and the need for mechanical ventilation (P<0.001). After a median hospital stay of 10 days, 132 patients were discharged home. The 1-year mortality was 40%. Only the presence of pleural effusion was found as a predictor for 1-year mortality. CONCLUSION: Most patients with APOE in this study are elderly, and have IHD, hypertension, diabetes and a previous history of APOE. The overall mortality is high (in-hospital, 12%: 1-year, 40%). Left ventricular dysfunction was associated with high in-hospital mortality, but not with long-term prognosis.

Prospective evaluation of pulmonary edema.

OBJECTIVES: To describe the clinical profile and hospital outcome of successive unselected patients with pulmonary edema hospitalized in an internal medicine department. DESIGN: Prospective, consecutive, unsolicited patients diagnosed with pulmonary edema. SETTING: An internal medicine department in a 900 tertiary care center. PATIENTS: A total of 150 consecutive unselected patients (90 males, 60 females; median age, 75 yrs). RESULTS: Ischemic heart disease, hypertension, various valvular lesions and diabetes mellitus were present in 85%, 70%, 53%, and 52% of patients, respectively. Acute myocardial infarction at admission was observed in 15% of patients. The most common precipitating factors associated with the development of pulmonary edema included: high blood pressure (29%), rapid atrial fibrillation (29%,) unstable angina pectoris (25%), infection (18%), and acute myocardial infarction (15%). Twenty-two patients (15%) were mechanically ventilated. Eighteen patients (12%) died while in the hospital, and the cause of death was cardiac pump failure in 82%. The median hospital stay was 10 days. Predictors for increase rate of in-hospital mortality included: diabetes (p<.05), orthopnea (p<.05), echocardiographic finding of moderate-to-severely depressed global left ventricular systolic function (p<.001), acute myocardial infarction during hospital stay (p<.001), hypotension/shock (p<.05), and the need for mechanical ventilation (p<.001). CONCLUSIONS: Most patients with pulmonary edema in the internal medicine department are elderly, having ischemic heart disease, hypertension, diabetes, and a previous history of pulmonary edema. The overall mortality is high (in-hospital, 12%) and the predictors associated with high in-hospital mortality are related to left ventricular myocardial function. The long median hospital stay (10 days) and the need for many cardiovascular drugs, impose a considerable cost in the management and health care of these patients.

Right atrial mass related to indwelling central venous catheters in patients undergoing dialysis.

Central venous catheters are used for the administration of fluids, drugs, blood products, total parenteral nutrition and for haemodynamic measurements. In patients with renal failure planned for dialysis, indwelling central venous catheters are used prior to forming an arterio-venous shunt. Infected right atrial thrombus is a rare phenomenon in adults and particularly unusual in patients undergoing dialysis. We describe two patients, undergoing dialysis for short periods, with indwelling central venous catheters and a right atrial mass, suspected for infected right atrial thrombus, detected by transoesophageal echocardiography.

One-year clinical follow-up with the serpentine balloon expandable stent: report of the first 100 patients.

BACKGROUND: We recently reported a high technical and 30-day clinical success rate among the first 100 patients treated with the tubular, serpentine design, stainless steel, balloon-expandable stent (beStent) in Israel. The present study examined the clinical results in these patients after the first year. METHODS: Seventy-eight men and 22 women were included in the study. Previous myocardial infarction, bypass surgery and percutaneous transluminal coronary angioplasty had occurred in 52%, 12% and 26% of the patients, respectively. Diabetes mellitus was present in 30 patients and hypertension in 34 patients. One hundred and forty-eight stents of 15, 25, and 35 mm lengths were used. The indications for stenting were suboptimal results (n = 85), bailout conditions (n = 10) or for the prevention of restenosis (n = 8), and lesion types were A (n = 10), B1 (n = 29), B2 (n = 20), and C (n = 44). All patients were clinically monitored with regular visits at 1, 3, 6, 9 and 12 months. RESULTS: Overall, the 12-month event-free survival rate was 82%. Subacute thrombosis occurred in two patients. There were two non-cardiac deaths, one O-wave myocardial infarction, six elective bypass surgeries and 12 target lesion revascularizations. Event-free survival was significantly higher for those with lesions shorter than 15 mm than for those with lesions longer than 15 mm (90% versus 67%, P = 0.003), and for women compared with men (96% versus 78%, P = 0.02). CONCLUSIONS: The initial experience with the beStent shows favorable long-term results with an overall event rate of 18% for this subset of relatively complex lesions; higher event rates were observed for longer lesions.

Interindividual heterogeneity in the hypoxic regulation of VEGF: significance for the development of the coronary artery collateral circulation.

BACKGROUND: The coronary artery collateral circulation may be beneficial in protecting against myocardial ischemia and necrosis. However, there is a tremendous interindividual variability in the degree of new collateral formation in patients with coronary artery disease. The basis for this interindividual heterogeneity is not understood. In this study we test the hypothesis that failure to generate collateral vessels is associated with a failure to appropriately induce with hypoxia or ischemia the angiogenic factor, vascular endothelial growth factor (VEGF). METHODS AND RESULTS: We correlated the VEGF response to hypoxia in the monocytes harvested from patients with coronary artery disease with the presence of collaterals visualized during routine angiography. We found that there was a highly significant difference in the hypoxic induction of VEGF in patients with no collaterals compared with patients with some collaterals (mean fold induction 1.9+/-0.2 versus 3.2+/-0.3, P<0.0001). After subjecting the data to ANCOVA, using as covariates a number of factors that might influence the amount of collateral formation (ie, age, sex, diabetes, smoking, hypercholesterolemia), patients with no collaterals still have a significantly lower hypoxic induction of VEGF than patients with collaterals. CONCLUSIONS: This study provides evidence in support of the hypothesis that the ability to respond to progressive coronary artery stenosis is strongly associated with the ability to induce VEGF in response to hypoxia. The observed interindividual heterogeneity in this response may be due to environmental, epigenetic, or genetic causes. This interindividual heterogeneity may also help to explain the variable angiogenic responses seen in other conditions such as diabetic retinopathy and solid tumors.

Continued expansion of the nitinol self-expanding coronary stent: angiographic analysis and 1-year clinical follow-up.

BACKGROUND: This study sought to report the first-year clinical outcome with the nitinol self-expanding coil stent and to provide angiographic data on the effect of self-expansion during implantation and follow-up. Self-expanding stents do not reach their nominal diameter at implantation. The long-term effects may therefore depend, in part, on continued expansion after initial implantation. METHODS: Between January 1995 and January 1996, 86 stents were deployed in 64 patients for indication of suboptimal results. All patients were clinically followed up for 1 year, and 72% had follow-up angiography. RESULTS: The majority (55%) of the lesions were class B2 or C. Balloon angioplasty increased the minimal lumen diameter from 1.07 +/- 0.73 mm to 2.24 +/- 0.57 mm; stent deployment further increased the diameter to 2.63 +/- 0.48 mm, and within-stent balloon dilatation to 2.96 +/- 0.62 mm. Angiographic follow-up performed at 7.8 +/- 1.1 months (range 7-9 months) showed that the minimal lumen diameter was 2.15 +/- 0.80 mm (late lumen loss of 0.81 +/- 0.69 mm), and the mean stent diameter expanded to 3.58 +/- 0.48 mm (self-expanding late stent gain of 0.62 +/- 0.55 mm). The extent of this expansion was inversely related to the late lumen loss (r = 0.67, slope 0.81, P <.01). At 1 year 51 (80%) of 64 patients were event free; 3 had undergone coronary artery bypass grafting, 2 had had a myocardial infarction, and 9 had repeat angioplasty. In the subgroup of a simple lesion (<15 mm) covered by 1 stent, 18 (86%) of 21 patients were event free. CONCLUSIONS: The self-expanding nitinol stent exerts its acute effect on minimal lumen diameter through its intrinsic radial force aided by balloon expansion. The stent continues to expand until it reaches its nominal diameter over the follow-up period. The extent of this expansion is inversely related to the late lumen loss, leading to an acceptable rate of long-term clinical events in this first cohort of patients with complex disease morphology.