RESUMEN
Despite significant advancements in managing acute ST-segment elevation myocardial infarctions, the prevalence of heart failure has not decreased. Emerging paradigms with a focus on reducing infarct size show promising evidence in the improvement of the incidence of heart failure after experiencing acute coronary syndromes. Limiting infarct size has been the focus of multiple clinical trials over the past decades and has led to left ventricular (LV) unloading as a potential mechanism. Contemporary use of microaxial flow devices for LV unloading has suggested improvement in mortality in acute myocardial infarction complicated by cardiogenic shock. This review focuses on clinical data demonstrating evidence of infarct size reduction and highlights ongoing clinical trials that provide a new therapeutic approach to the management of acute myocardial infarction.
Asunto(s)
Función Ventricular Izquierda , Humanos , Resultado del Tratamiento , Corazón Auxiliar , Infarto del Miocardio/terapia , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/epidemiología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/diagnóstico , Factores de Riesgo , Recuperación de la Función , Miocardio/patologíaRESUMEN
INTRODUCTION: The STEMI-DTU pilot study tested the early safety and practical feasibility of left ventricular (LV) unloading with a trans-valvular pump before reperfusion. In the intent-to-treat cohort, no difference was observed for microvascular obstruction (MVO) or infarct size (IS) normalized to either the area at risk (AAR) at 3-5 days or total LV mass (TLVM) at 3-5 days We now report a per protocol analysis of the STEMI-DTU pilot study. METHODS: In STEMI-DTU STUDY 50 adult patients (25 in each arm) with anterior STEMI [sum of precordial ST-segment elevation (ΣSTE) ≥4 mm] requiring primary percutaneous coronary intervention (PCI) were enrolled. Only patients who met all inclusion and exclusion criteria were included in this analysis. Cardiac magnetic resonance (CMR) imaging 3-5 days after PCI quantified IS/AAR and IS/TLVM and MVO. Group differences were assessed using Student's t-tests and linear regression (SAS Version-9.4). RESULTS: Of the 50 patients enrolled, 2 died before CMR imaging. Of the remaining 48 patients those without CMR at 3-5 days (n = 8), without PCI of a culprit left anterior descending artery lesion (n = 2), with OHCA (n = 1) and with ΣSTE < 4 mm (n = 5) were removed from this analysis leaving 32/50 (64 %) patients meeting all inclusion and exclusion criteria (U-IR, n = 15; U-DR, n = 17) as per protocol. Despite longer symptom-to-balloon times in the U-DR arm (228 ± 80 vs 174 ± 59 min, p < 0.01), IS/AAR was significantly lower with 30 min of delay to reperfusion in the presence of active LV unloading (47 ± 16 % vs 60 ± 15 %, p = 0.02) and remained lower irrespective of the magnitude of precordial ΣSTE. MVO was not significantly different between groups (1.5 ± 2.8 % vs 3.5 ± 4.8 %, p = 0.15). Among patients who received LV unloading within 180 min of symptom onset, IS/AAR was significantly lower in the U-DR group. CONCLUSION: In this per-protocol analysis of the STEMI-DTU pilot study we observed that LV unloading for 30 min before reperfusion significantly reduced IS/AAR compared to LV unloading and immediate reperfusion, whereas in the ITT cohort no difference was observed between groups. This observation supports the design of the STEMI-DTU pivotal trial and suggests that strict adherence to the study protocol can significantly influence the outcome.
Asunto(s)
Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Adulto , Humanos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Proyectos Piloto , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento , Reperfusión Miocárdica , Función Ventricular IzquierdaRESUMEN
An elderly man with cardiogenic shock who was found to have a thrombus burden in the right atrium was described. The thrombus was suctioned via the AngioVac device, with assistance from the Impella CP. This is the first reported case of the use of the AngioVac device in conjunction with left-sided mechanical circulatory devices.
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Corazón Auxiliar , Trombosis , Anciano , Humanos , Masculino , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Succión , Trombectomía , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: To assess the outcomes of the use of the percutaneous Impella RP device (Abiomed, Danvers, MA) in adolescents and young adults. BACKGROUND: Results of the Impella RP device have been reported in adults, but a multicenter experience in adolescents and young adults has yet to be reported. METHODS: Patients ≤21 years of age who underwent implantation of an Impella RP device for refractory right heart failure from June, 2016 to April, 2018 at nine U.S. Centers were included. RESULTS: A total of 12 adolescents, median age of 18 (14-21) years and median weight 74.4 (49-112.4) kg underwent Impella RP implantation (INTERMACS Profile 1 in nine and Profile 2 in three patients. The central venous pressure decreased from 20 (16-35) to 12 (7-17) mmHg, (p = .001). One patient was concomitantly supported with an intra-aortic balloon pump (IABP) and the rest with a percutaneous/surgically placed left ventricular assist device. There was one adverse event related to the Impella RP device (thrombosis requiring explant). The support duration was 6.5 days (4.8 hr-18.4 days) and survival to hospital discharge was 83%. At a median follow-up of 11 months (5 days-2.5 years), 8 of 12 (67%) patients are alive. CONCLUSIONS: In this multicenter experience, the Impella RP device was found to be efficacious and safe when used in adolescents and young adults. Further studies are warranted to identify suitable young/pediatric candidates for Impella RP therapy for right heart failure.
Asunto(s)
Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Hemodinámica , Implantación de Prótesis/instrumentación , Función Ventricular Derecha , Adolescente , Factores de Edad , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Mortalidad Hospitalaria , Humanos , Masculino , Diseño de Prótesis , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/mortalidad , Recuperación de la Función , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
Hemolysis is a potential limitation of percutaneously delivered left-sided mechanical circulatory support pumps, including trans valvular micro-axial flow pumps (TVP). Hemolytic biomarkers among durable left ventricular assist devices include lactate dehydrogenase (LDH) >2.5 times the upper limit of normal (ULN) and plasma-free hemoglobin (pf-Hb) >20 mg/dL. We examined the predictive value of these markers among patients with cardiogenic shock (CS) receiving a TVP. We retrospectively studied records of 116 consecutive patients receiving an Impella TVP at our institution between 2012 and 2017 for CS. Twenty-three met inclusion/exclusion criteria, and had sufficient pf-Hb data for analysis. Area under receiver-operator characteristic (ROC) curve for diagnosing hemolysis were calculated. Mean age was 62 ± 14 years and ejection fraction was 15 ± 5%. Mean duration of support was 5.4 ± 3.5 days. Pre-device LDH levels were >2.5x ULN in 71% (n = 5/7) of 5.0 and 29% of CP patients, while pre-device pf-Hb levels were >20 mg/dL in 14% (n = 1/7) of 5.0 and 25% (n = 4/16) of CP patients. Given elevated baseline LDH and pf-Hb levels, we defined hemolysis as a pf-Hb level >40 mg/dL within 72 h post-implant plus clinical evidence of device-related hemolysis. We identified that 30% (n = 7/23) had device-related hemolysis. Using ROC curve-derived cut-points, an increase in delta pf-Hb by >27mg/dL, not delta LDH, within 24 h after TVP implant (delta pf-Hb: C-statistic = 0.79, sensitivity: 57%, specificity: 93%, p <0.05) was highly predictive of hemolysis. In conclusion, we identified a change in pf-Hb, not LDH, levels is highly sensitive and specific for hemolysis in patients treated with a TVP for CS.
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Corazón Auxiliar/efectos adversos , Hemoglobinas/análisis , Hemólisis/fisiología , Choque Cardiogénico/terapia , Anciano , Femenino , Pruebas Hematológicas , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Choque Cardiogénico/sangreRESUMEN
BACKGROUND: Prognosis is poor for patients with decompensated advanced heart failure (HF) refractory to medical therapy. Evaluating candidacy for durable mechanical circulatory support (MCS), cardiac transplantation, or palliative care is complex, and time is often needed to stabilize the patient hemodynamically. The Impella 5.0 (Abiomed, Danvers, MA) is a minimally invasive axial-flow catheter capable of providing full temporary hemodynamic support. We report a multicenter series on the use of this device for bridge to decision (BTD) in decompensated advanced HF patients. METHODS: In a retrospective evaluation at 3 centers of patients with advanced HF who acutely decompensated and received the Impella 5.0 for BTD, we analyzed demographics, procedural characteristics, in-hospital and intermediate-term outcomes, and in-hospital complications. RESULTS: There were 58 patients who met inclusion criteria from 2010 to 2015. All were inotrope dependent. The mean ejection fraction was 13%, and median age was 59 years (interquartile range, 48-64 years). Mean duration of support was 7 days (range, 0-22 days). Thirty-nine patients survived to next therapy (67%), with most receiving durable MCS (n = 20) or heart transplantation (n = 15). In-hospital complications included bleeding (n = 9) and hemolysis (n = 4). Of patients who survived to the next therapy, 1-year survival was 65% for those who received durable MCS, 87% for those who received a transplant, and 75% for those who were stabilized and weaned. CONCLUSIONS: The Impella 5.0 may provide a BTD strategy for patients with advanced HF and acute hemodynamic instability. Prospective studies are needed to evaluate the safety and effectiveness of this device in this patient population.
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Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Enfermedad Aguda , Toma de Decisiones Clínicas , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Implantación de Prótesis/métodos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
Rotational atherectomy is effective and safe in selected complex calcified lesions. Despite an older population with more comorbidities, rotational atherectomy is not associated with worse clinical outcomes. Coronary interventionalists need to be well-trained in both the use of atherectomy techniques as well as how to manage potential complications.
Asunto(s)
Aterectomía Coronaria/mortalidad , Aterectomía Coronaria/métodos , Enfermedad de la Arteria Coronaria/terapia , Mortalidad Hospitalaria , Infarto del Miocardio/terapia , Sistema de Registros , Femenino , Humanos , MasculinoRESUMEN
Chronic stress is associated with increased risk of cardiovascular diseases. Aging is also associated with vascular dysfunction. We hypothesize that chronic stress accelerates collateral dysfunction in old mice. Mice were subjected to either chronic social defeat (CSD) or chronic cold stress (CCS). The CSD mice were housed in a box inside an aggressor's cage and exposed to the aggressor. The CCS group was placed in iced water. After chronic stress, mice underwent femoral artery ligation (FAL) and flow recovery was measured. For the CSD group, appearance and use scores of the foot and a behavioral test were performed. CSD impaired collateral flow recovery after FAL. Further, stressed mice had greater ischemic damage, impaired foot function, and altered behavior. The CCS mice also showed impaired collateral flow recovery. Chronic stress causes hind limb collateral dysfunction in old mice, a conclusion reinforced by the fact that two types of stress produced similar changes.
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Circulación Colateral , Arteria Femoral/fisiopatología , Isquemia/fisiopatología , Estrés Psicológico/fisiopatología , Animales , Conducta Animal , Enfermedad Crónica , Frío , Modelos Animales de Enfermedad , Arteria Femoral/cirugía , Isquemia/etiología , Isquemia/psicología , Ligadura , Masculino , Ratones Endogámicos C57BL , Recuperación de la Función , Flujo Sanguíneo Regional , Conducta Social , Estrés Psicológico/etiología , Estrés Psicológico/psicología , Factores de TiempoRESUMEN
The primary purpose of this investigation was to determine whether ApoE(-/-) mice, when subjected to chronic stress, exhibit lesions characteristic of human vulnerable plaque and, if so, to determine the time course of such changes. We found that the lesions were remarkably similar to human vulnerable plaque, and that the time course of lesion progression raised interesting insights into the process of plaque development. Lard-fed mixed-background ApoE(-/-) mice exposed to chronic stress develop lesions with large necrotic core, thin fibrous cap and a high degree of inflammation. Neovascularization and intraplaque hemorrhage are observed in over 80% of stressed animals at 20 weeks of age. Previously described models report a prevalence of only 13% for neovascularization observed at a much later time point, between 36 and 60 weeks of age. Thus, our new stress-induced model of advanced atherosclerotic plaque provides an improvement over what is currently available. This model offers a tool to further investigate progression of plaque phenotype to a more vulnerable phenotype in humans. Our findings also suggest a possible use of this stress-induced model to determine whether therapeutic interventions have effects not only on plaque burden, but also, and importantly, on plaque vulnerability.
Asunto(s)
Aterosclerosis/etiología , Aterosclerosis/patología , Modelos Animales de Enfermedad , Placa Aterosclerótica/etiología , Placa Aterosclerótica/patología , Estrés Psicológico/complicaciones , Animales , Aterosclerosis/sangre , Aterosclerosis/complicaciones , Presión Sanguínea , Colesterol/sangre , Estenosis Coronaria/complicaciones , Estenosis Coronaria/patología , Corticosterona/sangre , Hemorragia/complicaciones , Hemorragia/patología , Humanos , Inflamación/sangre , Inflamación/complicaciones , Inflamación/patología , Ratones , Ratones Endogámicos C57BL , Necrosis , Neovascularización Patológica/complicaciones , Neovascularización Patológica/patología , Neuropéptido Y/sangre , Placa Aterosclerótica/complicaciones , Estrés Psicológico/sangreRESUMEN
OBJECTIVES: The aim of this study was to explore the clinical utility of a commercially available centrifugal flow pump as a centrifugal flow-right ventricular support device (CF-RVSD) in patients with right ventricular failure (RVF). BACKGROUND: RVF is associated with high in-hospital mortality. Limited data regarding efficacy of the CF-RVSD for RVF exist. METHODS: We retrospectively reviewed data from 46 patients receiving a CF-RVSD for RVF from a registry comprising data from 8 tertiary-care hospitals in the United States. CF-RVSD use was recorded in the setting of acute myocardial infarction; myocarditis; chronic left heart failure; after valve surgery, orthotopic heart transplantation, left ventricular assist device surgery, coronary bypass grafting. Devices were implanted via the percutaneous (n = 22) or surgical (n = 24) route. RESULTS: No intraprocedural mortality was observed. Mean time from admission to CF-RVSD implantation was 5.7 ± 8.5 days, with a mean of 6,769 ± 789 rotations/min, providing 4.2 ± 1.3 l/min of flow. Mean duration of support was 5.4 ± 5.1 days. Mean arterial pressure (65 ± 12 mm Hg vs. 73 ± 14 mm Hg; p < 0.05), right atrial pressure (21 ± 8 mm Hg vs. 16 ± 7 mm Hg; p = 0.05), pulmonary artery systolic pressure (43 ± 15 mm Hg vs. 33 ± 15 mm Hg; p = 0.01), and cardiac index (1.7 ± 0.7 vs. 2.2 ± 0.6; p = 0.01) were improved within 48 h of CF-RVSD implantation. Total in-hospital mortality was 57% and was lowest in the setting of left ventricular assist device implantation, chronic left heart failure, and acute myocardial infarction. Increased age, biventricular failure, and Thrombolysis In Myocardial Infarction-defined major bleeding were associated with increased in-hospital mortality. CONCLUSIONS: Use of the CF-RVSD for RVF is clinically feasible and associated with improved hemodynamic status. Observations from the registry of patients who have received this device may support the development of prospective studies that will examine the role of percutaneous circulatory support for RVF.
Asunto(s)
Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Dipeptidyl peptidase IV (DPP-IV) is not only important in pancreatic ß-cell regulation but also has proinflammatory actions that can contribute to atherosclerosis progression. Previously, we showed that DPP-IV is co-localized with CD31 (an endothelial cell marker) in the neovessels within the human atherosclerotic plaques. These characteristics of DPP-IV may predispose patients with coronary artery disease (CAD) to plaque rupture and thus to myocardial infarction. The goal of this investigation was to determine whether genetic alterations in DPP-IV predispose to plaque vulnerability and myocardial infarction (MI). METHODS: Between Aug 2004, and March 2007, blood samples of patients (age <60) with angiographically documented CAD were collected. Demographic, clinical, risk factor, and angiographic data were recorded. Eight hundred and seventy five patients of European ancestry with angiographic CAD were divided into those with MI (n=421) and those without (n=454). A genome-wide association study was performed using the Affymetrix 6.0 chip to identify loci that predispose to MI. In the current study we only focused on DPP4 gene to assess the association of single nucleotide polymorphisms (SNPs) in the DPP-IV gene and risk of MI in patients with CAD. For genotyped SNPs, association was tested by logistic regression with significance level of 0.05. Plasma DPP-IV level was measured using a commercial ELISA kit. RESULTS: Average patients' age at diagnosis of CAD was 46.8years for MI group and 50.8 in the non MI group. There was no difference in distribution of traditional risk factors between the two groups. We identified one SNP (rs3788979) that was significantly related to angiographic CAD with MI, vs. without MI (OR: 1.36, p=0.03). The association of the identified SNP to MI risk was not attenuated after adjustment for traditional risk factors. The SNP was associated with lower levels of plasma DPP-IV (p=0.005). Moreover, CAD patients with the major alleles (GG) and no MI had highest plasma DPP-IV levels. (481.6, p=0.002). CONCLUSIONS: A polymorphism in the DPP-IV gene in patients with known CAD may increase the risk of MI. This SNP is associated with decreased plasma DPP4 level in patients with MI.
Asunto(s)
Aterosclerosis/genética , Dipeptidil Peptidasa 4/genética , Infarto del Miocardio/genética , Polimorfismo Genético/genética , Alelos , Aterosclerosis/complicaciones , Aterosclerosis/epidemiología , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/genética , ADN/genética , Ensayo de Inmunoadsorción Enzimática , Femenino , Estudio de Asociación del Genoma Completo , Genotipo , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Placa Aterosclerótica/genética , Placa Aterosclerótica/patología , Polimorfismo Genético/fisiología , Polimorfismo de Nucleótido Simple , Análisis por Matrices de Proteínas , RiesgoRESUMEN
Blood flow restoration to ischemic tissue is affected by various risk factors. The aim of this study was to examine gender effects on arteriogenesis and angiogenesis in a mouse ischemic hindlimb model. C57BL/6J mice were subjected to unilateral hindlimb ischemia. Flow recovery was less and hindlimb use impairment was greater in females. No gender difference in vessel number was found at baseline, although 7 days postsurgery females had fewer α-smooth muscle actin-positive vessels in the midpoint of the adductor region. Females had higher hindlimb vascular resistance, were less responsive to vasodilators, and were more sensitive to vasoconstrictors postligation. Western blotting showed that females had higher baseline levels of vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) in the calf, while 7 days postligation males had higher levels of VEGF, eNOS, and phosphorylated vasodilator stimulated phosphoprotein. Females had less angiogenesis in a Matrigel plug assay and less endothelial cell proliferation in vitro. Females have impaired recovery of flow, a finding presumably caused by multiple factors including decreased collateral remodeling, less angiogenesis, impaired vasodilator response, and increased vasoconstrictor activity; our results also suggest the possibility that new collateral formation, from capillaries, is impaired in females.
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Arteria Femoral/fisiología , Miembro Posterior/irrigación sanguínea , Isquemia/fisiopatología , Flujo Sanguíneo Regional/fisiología , Caracteres Sexuales , Animales , Femenino , Miembro Posterior/metabolismo , Isquemia/sangre , Masculino , Ratones , Ratones Endogámicos C57BL , Modelos Animales , Neovascularización Fisiológica/fisiología , Óxido Nítrico Sintasa de Tipo III/metabolismo , Factor A de Crecimiento Endotelial Vascular/metabolismo , Resistencia Vascular/fisiologíaRESUMEN
We present a 30-year-old man admitted with generalized cutaneous lesions, fever and cough. Examination of skin biopsies of a papular lesion revealed dense neutrophilic infiltration of the upper dermis, so these lesions were diagnosed as neutrophilic dermatosis. Peripheral blood examination and bone marrow findings confirmed the diagnosis of myelodysplastic syndrome with excess blasts. The cutaneous lesions improved after administration of corticosteroid and follow-up bone marrow examination revealed a normocellular marrow. One year later he referred with acute myelogenous leukemia (AML-M0). Unfortunately, he did not respond to treatment and died a few months later due to disease progression.