Impact of acute renal failure following percutaneous coronary intervention on long-term mortality.

BACKGROUND: Acute renal failure (ARF) following percutaneous coronary intervention (PCI) has been shown to be associated with a worse outcome. Whether this event should be considered as a marker of disease severity or an independent contributor to mortality is still unclear. METHODS: In a multicenter, prospective cohort study we investigated the predictive variables and the impact of postprocedural ARF on 2-year all-cause mortality in 2860 consecutive patients (50% with stable angina and 50% with non-ST-elevation acute coronary syndromes) undergoing PCI. Serum creatinine determinations were made immediately before and 24 h after PCI. ARF was defined as an increase in serum creatinine of > or =0.5 mg/dl over baseline. RESULTS: One hundred and six patients (3.7%) experienced ARF. At logistic regression analysis, ARF was associated with pre-existing low values of estimated glomerular filtration rate, reduced left ventricular ejection fraction, hypertension, and prior coronary bypass surgery. Mortality data at 2 years were available for all patients: 119 patients (4.16%) had died, 3.9% of those without and 11.3% of those with ARF (univariate hazard ratio 3.16; 95% confidence interval 1.68-5.94; P = 0.0004). At Cox regression analysis, the significant predictors of mortality were age, ejection fraction, preprocedural estimated glomerular filtration rate, PCI failure, atrial fibrillation, diabetes mellitus, and fluoroscopy time. In this comprehensive mortality model, ARF maintained a borderline statistical significance (hazard ratio 1.83, 95% confidence interval 0.98-3.44; P = 0.06). CONCLUSIONS: ARF following PCI occurs almost exclusively in patients with chronic kidney disease or left ventricular dysfunction. These risk factors are also among the most powerful predictors of long-term mortality and are likely to explain most of the association between postprocedural ARF and long-term mortality. After correction for clinical determinants, however, postprocedural ARF maintains a clinically significant impact on mortality that must be taken into account for benefit vs. risk evaluation of PCI in individual patients.

Reduced coronary flow reserve and parasympathetic dysfunction in patients with cardiovascular syndrome X.

OBJECTIVE: Although cardiovascular syndrome X was described many years ago, its causes are still unclear. Many studies have addressed the autonomic function, whereas others have investigated the coronary reserve. The purpose of this study was to investigate the correlations between parasympathetic dysfunction and coronary flow reserve deficiency. BASIC METHODS: Eleven consecutive women suffering from cardiovascular syndrome X were enrolled in the study. All the patients underwent the analysis of heart rate and blood pressure variability, the cold face test and noninvasive evaluation of the coronary flow reserve by transthoracic echocardiography. Comparison was made with healthy volunteers. RESULTS: Seven patients (64%) showed vagal impairment in the analysis of heart rate and blood pressure variability and a pathological response to the cold face test, whereas four patients (36%) did not show significant differences from the control group. In these three groups, patients with and without vagal impairment and controls, there was a difference in the mean diastolic coronary velocity reserve (1.94+/-0.48; 3.73+/-0.95, 2.88+/-0.55, P=0.0005) and in maximal diastolic velocity reserve (2.00+/-0.48, 3.26+/-0.64, 2.65+/-0.57, P=0.0047). Post-hoc analysis demonstrated that the mean and maximal diastolic velocity reserves of the patients with vagal impairment seemed to be reduced compared with those of the other groups (P<0.05), which were similar. CONCLUSIONS: This study confirmed that syndrome X patients represent a heterogeneous group. More than half of the patients exhibited vagal dysfunction. In these patients, coronary flow reserve was abnormal compared with controls and other syndrome X patients without vagal impairment.

[Percutaneous coronary intervention and immediate re-transfer to the referring hospital for patients with acute coronary syndrome. A single-center experience]. / Angioplastica coronarica e immediato ritrasferimento all'ospedale di provenienza nei pazienti con sindrome coronarica acuta. La nostra esperienza.

BACKGROUND: Current guidelines recommend early transfer of patients with acute coronary syndromes from primary care centers to hospitals with cath lab facilities. Few data exist about safety of re-transfer to primary care centers immediately after successful percutaneous coronary interventions. METHODS: We analyzed data regarding 102 consecutive patients (73 male, 29 female, mean age 69 +/- 10.9 years) transferred to the Bolzano hospital from centers without cath lab facilities for urgent percutaneous coronary intervention in acute coronary syndromes and planned immediate re-transfer after the procedure. Data about complications during re-transfer were obtained using a prepared data sheet completed by physicians and/or paramedics involved in the transport. RESULTS: Eighty-eight (87.1%) patients were re-transferred immediately after the cath lab procedure. Arterial hemostasis was achieved with arterial closure devices before leaving the cath lab. During re-transfer, 61 (69%) patients were accompanied by physicians and 27 (31%) patients by paramedics. No ischemic, arrhythmic or hemorrhagic complications were observed. CONCLUSIONS: In our experience immediate re-transfer to the referring hospital after successful urgent percutaneous coronary intervention for acute coronary syndrome is feasible and safe. If the patient is clinically stable after the procedure, re-transfer may not require the presence of a physician.

[Can clopidogrel be responsible for neutropenia?]. / Può il clopidogrel causare neutropenia?

We describe a case of neutropenia in an 80-year-old female patient. After a coronary intervention procedure with stent implantation, therapy with clopidogrel was started. Thirty-eight days after the beginning of this therapy, a serious lowering of neutrophil levels was found. Common causes of neutropenia were excluded and, after clopidogrel withdrawal, neutrophil levels normalized within a few days.

Percutaneous retrieval of a broken catheter from the pulmonary artery.

We describe a case regarding the percutaneous retrieval of a broken catheter from the pulmonary artery of a 54-year-old female patient in which we successfully used a "Goose Neck" snare. The analysis of relevant literature and the successful outcome of the case confirm that the percutaneous retrieval of a foreign body is a feasible, sure, and effective procedure.

Serum troponin I level after external electrical direct current synchronized cardioversion in patients with normal or reduced ejection fraction: no evidence of myocytes injury.

BACKGROUND: External electrical cardioversion (EEC) has been suggested as a cause of myocardial damage, but results from several previously published studies are conflicting. HYPOTHESIS: The purpose of the study was to evaluate myocardial electrical injury caused by EEC. METHODS: After elective EEC for atrial fibrillation (AF), cardiac troponin I (cTnI) was measured in 193 consecutive patients attending the Cardiology Department of the San Maurizio Hospital of Bolzano for elective EEC of AF over a period of 13 months. External electrical cardioversion was performed by one of the attending cardiologists with a synchronized monophasic defibrillator. Blood sample for cTnI was taken 18-20 h after EEC. RESULTS: Of 193 patients, 183 (95%) were successfully cardioverted. Mean number of shocks was 1.46 and the mean total energy discharged per procedure was 379.4 +/- 229.2 J. Cardiac troponin remained under the limit of confidence for all patients with a mean value of 0.017 +/- 0.021 mcrg/l. No correlation between total energy delivered and cTnI was found. In the subgroup of patients with low ejection fraction, none had elevated cTnI, and no difference in cTnI values between these and patients with an ejection fraction > 40% was found. CONCLUSIONS: The results of our analysis indicate that EEC caused no myocardial injury even in patients with low ejection fraction.

Age-related variations of left ventricular endocardial and midwall function in healthy infants, children, and adolescents.

BACKGROUND: In pediatric age echocardiographic evaluation of left ventricular systolic function is usually based on indexes obtained by measurements at the endocardial level. In the presence of ventricular hypertrophy this may lead to an overestimation of systolic function. The aim of this study was to assess the developmental changes of left ventricular systolic mechanics measured at the endocardial and midwall levels. METHODS: In 239 normal subjects divided into six age groups we measured left ventricular end-diastolic volume, mass and mass/volume ratio, fractional shortening, and rate-corrected mean velocity of circumferential shortening at the endocardial and midwall levels. Endocardial meridional end-systolic stress and midwall circumferential end-systolic stress were considered as indexes of afterload. Relations of extent and velocity of fiber shortening to afterload at the endocardial and midwall levels were used to assess left ventricular contractility. RESULTS: Blood pressure, left ventricular afterload, volume and mass increased, whereas the mass/volume ratio remained stable during growth. Fractional shortening and mean velocity of circumferential shortening at the endocardial level decreased and showed an inverse relation to afterload. Midwall fractional shortening and rate-corrected mean velocity of circumferential shortening were lower during the first months and did not change during the first year of life. CONCLUSIONS: Left ventricular volume and mass increase with age, mass/volume ratio remains almost constant while afterload increases. Endocardial systolic function indexes are higher in the first period of life, due to low afterload and increased mass/volume ratio. In the first months of life the left ventricular myocardium shows a greater sensitivity to changes in afterload and a reduced contractility measured at the midwall level.

Factors affecting left ventricular remodelling and mechanics in the long-term follow-up after successful repair of aortic coarctation.

AIMS: To identify factors predisposing to abnormal left ventricular geometry and mechanics in 52 patients after successful repair of aortic coarctation. METHODS AND RESULTS: We evaluated left ventricular remodelling, systolic midwall mechanics, and isthmic gradient by echo-Doppler, systemic blood pressure at rest/exercise and by ambulatory blood pressure monitoring, and the aortic arch by magnetic resonance imaging. Echocardiographic findings were compared with those of 142 controls. The patients with aortic coarctation showed an increased indexed left ventricular end-diastolic volume, increased mass index, increased ratio of mass to volume and systolic chamber function. The contractility, estimated at midwall level, was increased in 21 percent of the patients. In 26 (50 percent) of the patients, we found abnormal left ventricular geometry, with 9 percent showing concentric remodelling, 33 percent eccentric hypertrophy, and 8 percent concentric hypertrophy. These patients were found to be older, underwent a later surgical repair, and to have higher systolic blood pressures at rest and exercise as well as during ambulatory monitoring. The relative mural thickness and mass index of the left ventricle showed a significant correlation with different variables on uni- and multivariate analysis. Age and diastolic blood pressure at rest are the only factors associated with abnormal left ventricular remodelling. CONCLUSIONS: Patients who have undergone a seemingly successful surgical repair of aortic coarctation may have persistently abnormal geometry with a hyperdynamic state of the left ventricle. This is more frequent in older patients, and in those with higher diastolic blood pressures.

Left ventricular remodeling, systolic function, and diastolic function in young adults with beta-thalassemia intermedia: a Doppler echocardiography study.

BACKGROUND: The aim of this study was to investigate the left ventricular (LV) remodeling and function in 24 asymptomatic young adults affected by beta-thalassemia intermedia (TI), in order to compare the obtained data with that of 80 patients affected by beta-thalassemia major (TM) and 65 healthy subjects. METHODS: LV volumes and shapes, mass index, mass/volume ratio, systolic and diastolic function, stroke volume, and cardiac index were determined by two-dimensional and M-mode echocardiography. RESULTS: In the TM and TI groups, LV volumes, diastolic and systolic shapes were significantly different from the control subjects, but the ejection fraction was slightly reduced only in the TM group. The TI group had larger LV volumes than did the TM group (mean [+/- SD] end-diastolic volume index, 99.4 +/- 21.9 vs 82.7 +/- 21.5 mL/m(2), respectively [p < 0.005]; mean end-systolic volume index, 42.8 +/- 12.2 vs 36.1 +/- 12.9 mL/m(2), respectively [p < 0.05]). Both groups showed an increase of the LV mass index, but the mass/volume ratio did not differ from the control subjects. The systolic volume index and the cardiac index were increased in both groups, but the increase was more pronounced in the TI group. Fractional shortening (FS) and the mean velocity of circumferential shortening (mVCFc) were decreased in the TM group (FS, 33.6 +/- 5.5% vs 36.9 +/- 4.1, respectively [p < 0.001]; mVCFc, 1.06 +/- 0.18 vs 1.17 +/- 0.12 circumference per second, respectively [p < 0.0001]). The LV contractile state was depressed only in the TM group, and the preload index was normal in both. LV filling showed an increase in the total flow velocity integral due to increases in the peak E wave (E) and peak A wave (A) velocities and integrals, with an increase of the E/A ratio in the TM group and a slight decrease in the TI group. The isovolumic relaxation time was prolonged in both groups. There was no major derangement in the pulmonary venous flow. CONCLUSIONS: Asymptomatic young adults with TI show significant increases in LV volumes, LV mass, and cardiac index that are more pronounced than those in TM patients. LV systolic function is preserved in the TI group but is slightly depressed in the TM group due to the increase of afterload and to reduced contractility. The hemodynamic and hematologic factors involved in the etiopathogenesis of these findings are discussed, such as the treatment strategy.