Transient stress-related hyperviscosity and endothelial dysfunction in Takotsubo syndrome: a time course study.

Takotsubo syndrome (TTS) is an acute and usually reversible heart failure syndrome, frequently associated with emotional or physical stress. Its pathophysiology remains largely unclear, although several mechanisms related to catecholaminergic storm have been proposed. In this study we analyzed during the acute phase of TTS and at follow-up both hemorheological parameters and biomarkers of endothelial damage, whose time course has never been fully explored. In 50 TTS women, we analyzed several hemorheological parameters [whole blood viscosity (WBV) at 0.512 s-1 and at 94.5 s-1, plasma viscosity (PLV), erythrocyte deformability and aggregation index] as well as biomarkers of endothelial dysfunction [von Willebrand Factor (vWF), Plasminogen activator inhibitor-1 and factor VIII levels] during the acute phase and after a median 6 months follow-up. These variables were also assessed in 50 age-matched healthy women. Respect to follow-up, in the acute phase of TTS we observed higher values of white blood cell count, fibrinogen, WBV at low and high shear rates, PLV, erythrocyte aggregation index and lower values of erythrocyte elongation index. Moreover, all biomarkers of endothelial dysfunction resulted significantly higher in the acute phase. During follow-up WBV at 94.5 s-1, erythrocyte elongation index and vWF resulted significantly altered with respect to controls. The results of this study confirm the role of hyperviscosity and endothelial dysfunction in TTS pathophysiology. Moreover, they suggest the persistence of alterations of erythrocyte deformability and endothelial dysfunction even beyond the acute phase that could be the target of therapeutic strategies also during follow-up.

Transcatheter Aortic Valve Implantation in Younger Patients: A New Challenge.

The number of aortic stenosis patients in Western countries is increasing, along with better life conditions and expectancies. Presently, the volume of percutaneous transcatheter aortic valve implantations (TAVIs) is incessantly increasing, and has already overcome the surgical replacement procedure volume. According to the literature, TAVI is a feasible procedure even among low surgical risk patients, and American guidelines have extended the indications for TAVI, including shifting patient evaluations from high/low STS scores to old/young patients, a "paradigm shift" of aortic stenosis evaluation. As a result, low-risk young (<75 years-old) population management could be the next challenge in cardiology. To manage the life conditions of a 65 year old patient affected by aortic stenosis who is undergoing TAVI, one of the most crucial issue will be bioprosthesis durability and the appropriate intervention to make in cases of valve dysfunction or failure.

Estimation of central arterial pressure from the radial artery in patients undergoing invasive neuroradiological procedures.

BACKGROUNDS: Central arterial pressure can be derived from analysis of the peripheral artery waveform. The aim of this study was to compare central arterial pressures measured from an intra-aortic catheter with peripheral radial arterial pressures and with central arterial pressures estimated from the peripheral pressure wave using a pressure recording analytical method (PRAM). METHODS: We studied 21 patients undergoing digital subtraction cerebral angiography under local or general anesthesia and equipped with a radial arterial catheter. A second catheter was placed in the ascending aorta for central pressure wave acquisition. Central (AO) and peripheral (RA) arterial waveforms were recorded simultaneously by PRAM for 90-180 s. During an off-line analysis, AO pressures were reconstructed (AOrec) from the RA trace using a mathematical model obtained by multi-linear regression analysis. The AOrec values obtained by PRAM were compared with the true central pressure value obtained from the catheter placed in the ascending aorta. RESULTS: Systolic, diastolic and mean pressures ranged from 79 to 180 mmHg, 47 to 102 mmHg, and 58 to 128 mmHg, respectively, for AO, and 83 to 174 mmHg, 47 to 107 mmHg, and 60 to 129 mmHg, respectively, for RA. The correlation coefficients between AO and RA were 0.86 (p < 0.01), 0.83 (p < 0.01) and 0.86 (p < 0.01) for systolic, diastolic and mean pressures, respectively, and the mean differences - 0.3 mmHg, 2.4 mmHg and 1.5 mmHg. The correlation coefficients between AO and AOrec were 0.92 (p < 0.001), 0.87 (p < 0.001) and 0.92 (p < 0.001), for systolic, diastolic and mean pressures, respectively, and the mean differences 0.01 mmHg, 1.8 mmHg and 1.2 mmHg. CONCLUSIONS: PRAM can provide reliable estimates of central arterial pressure.

The Use of Pressure Recording Analytical Method in Patients Undergoing Endovascular Repair for Abdominal Aortic Aneurysm: The Impact on Clinical Decisions for the Appropriate Postoperative Setting and Cost-effective Analysis.

OBJECTIVE: To analyze the use of the Pressure Recording Analytical Method (PRAM), an hemodynamic monitoring system, in evaluating intraoperative and postoperative hemodynamic instability in patients undergoing endovascular repair for abdominal aortic aneurysm, and to evaluate if the decision to refer patients to a ordinary ward or to a Cardiac Step-Down Unit (CSDU) after the intervention on the basis of intraoperative hemodynamic monitoring could be more cost-effective. MATERIALS AND METHODS: After preoperative clinical evaluation, 44 patients were divided in this non-randomised study into two groups according to their postoperative destination: Group 1-ward (N=22) and Group 2-CSDU (N=22). All patients underwent monitoring with PRAM during the intervention and in the 24 postoperative hours, measuring several indices of myocardial contractility and other hemodynamic variables. RESULTS: According to the variability of two parameters, Stroke Volume Variation and Pulse Pressure Variation, patients were classified as stable or unstable. Unstable patients showed a significant alteration in several hemodynamic indices, in comparison to stable ones. According to the intraoperative monitoring, eight high risk patients could have been sent to an ordinary ward due to their stability, with a reduction in the improper use of CSDU and, consequently, in costs. CONCLUSIONS: Hemodynamic monitoring with PRAM can be useful in these patients, both for intraoperative management and for the choice of the more appropriate postoperative setting, possibly reducing the improper use of CSDU for hemodynamically stable patients who are judged to be at high risk preoperatively, and re-evaluating low surgical risk patients with an unstable intraoperative pattern, with a possible reduction in costs.

Congestive heart failure and decongestion ability of two different treatments: continuous renal replacement and diuretic therapy: experience of a cardiac step down unit.

INTRODUCTION: The rehospitalization rate for decompensated heart failure (HF) is high and can be ascribed also to a suboptimal decongestion before discharge. Congestion can be treated with diuretics or continuous renal replacement therapy (CRRT). Aim of this study was to evaluate if diuretics and CRRT, used in agreement to international guidelines, may have a dissimilar decongestion ability in patients with decompensated HF with different baseline characteristics. METHODS: In 88 patients with HF (NYHA class Ill-IV) we evaluated the effect of CRRT (n = 46) and intravenous diuretics (n = 42) on clinical and instrumental signs of congestion. A clinical score was obtained as the sum of signs and symptoms of HF to estimate the severity of each patient's clinical condition.The choice of diuretics or CRRT was guided by renal impairment or diuretics' resistance. RESULTS: A significant reduction in clinical HF score was observed in the CRRT group at discharge vs admission (1.3 +/- 1.9 vs 5.7 +/- 2.3, P < 0.001) and in the diuretic group (1.8 +/- 1.4 vs 3.7 +/- 1.6, P < 0.001), while a significant reduction in radiographic signs of pulmonary congestion, pleural effusion, echocardiographic systolic arterial pulmonary pressure (43.41 +/- 13.6 vs 50.5 +/- 20.2 mmHg, P < 0.005) and NT-proBNP (6,676 vs 15,492 pg/ml, P < 0.05) were observed only in CRRT patients. Moreover, also urine output significantly increased only in CRRT patients (1.8 +/- 0.8 vs 0.9 +/- 0.6 ml/h/kg, P < 0.001). CONCLUSIONS: CRRT and diuretics showed an equivalent ability in relieving clinical signs and symptoms of HF but only CRRT was able to significantly improve several instrumental and biohumoral indicators of congestion.

Variations in Microcirculatory and Hemodynamic Parameters during Oncological Demolitive-Reconstructive Head and Neck Surgery: A Protocol for an Observational Study.

(1) Background: Oncological demolitive-reconstructive surgeries in the head and neck region cause significant stress on patients' biohumoural, cardiac, and vascular systems, leading to disturbances in macrocirculatory and microcirculatory parameters. Traditional monitoring addresses the symptoms, but not the underlying cause. Microcirculatory assessments complement macrocirculatory monitoring, and bladder-catheter-based technology offers a better representation of central microcirculation. Flap reconstruction surgeries involve demolitive and reconstructive phases, requiring optimal tissue perfusion. The literature lacks a consensus on macro-microcirculation coupling, and there is no agreement on the use of vasopressors during head and neck surgeries. Evidence-based guidelines are lacking, resulting in variations in vasopressor administration. (2) Methods: This is a 12-month observational, prospective study conducted in a single center. It aims to evaluate the impact of macro-microcirculation coupling on clinical complications in head and neck surgery. All consecutive patients undergoing oncologic surgery requiring flap reconstruction and meeting the inclusion criteria will be enrolled. The study will utilize standard hemodynamic monitoring and bladder catheterization for measuring urine output and temperature. (3) Conclusions: The study aims to evaluate the coupling of macro- and microcirculation in head and neck surgeries, assess hemodynamic parameters and microcirculatory changes, and investigate their association with postoperative complications. The results can enhance patient care and surgical outcomes.

The hemodynamic and respiratory effects of cuirass ventilation in healthy volunteers: Part 1.

OBJECTIVE: Negative-pressure ventilation (NPV) by external cuirass (RTX; Deminax Medical Instruments Limited, London, UK) in intubated patients after cardiac surgery improves hemodynamics measured by pulmonary artery catheter (PAC)-based methods, with an increased cardiac output (CO) and stroke volume (SV), without changing the heart rate (HR). The less-invasive pressure recording analytical method (PRAM) (Mostcare; Vytech Health srl, Padova, Italy) allows radial artery-based monitoring of the CO, SV, SV variation, and cardiac cycle efficiency (CCE). The authors investigated the hypothesis that NPV improves PRAM-based hemodynamics and arterial blood gas analysis in spontaneously breathing subjects. DESIGN: A clinical investigation. SETTING: A teaching hospital. PARTICIPANTS: Ten healthy volunteers. INTERVENTIONS: Subjects underwent 5 consecutive experimental ventilation modalities lasting 5 minutes: (1) baseline (no cuirass ventilation), (2) mode 1: cuirass ventilation with a continuous negative pressure of -20 cmH(2)O, (3) first rest period (no cuirass ventilation), (4) mode 2: cuirass ventilation in control mode of 12 breaths/min at -20 cmH(2)O, and (5) second rest period. MEASUREMENTS AND MAIN RESULTS: PRAM parameters were analyzed throughout the final minute of each experimental modality, which concluded with arterial blood gas sampling. Both NPV modes significantly reduced HR without changing CO or systemic vascular resistance. Mode 1 significantly increased CCE and decreased SVV. PO(2) decreased in both rest modes compared with baseline. This was prevented by NPV. In 5 smokers, PO(2) significantly increased in the control mode compared with first rest period. The control mode NPV improved oxygenation with a reduced PCO(2) and reciprocally increased pH. CONCLUSIONS: Five minutes of NPV improves hemodynamics and oxygenation in healthy subjects.

The hemodynamic and respiratory effects of continuous negative and control-mode cuirass ventilation in recently extubated cardiac surgery patients: Part 2.

OBJECTIVE: Negative-pressure ventilation (NPV) by external cuirass (RTX; Deminax Medical Instruments Limited, London, UK) in intubated patients after cardiac surgery improves hemodynamics measured by pulmonary artery catheter (PAC)-based methods with increased cardiac output (CO) and stroke volume (SV) without changing the heart rate (HR). The less-invasive pressure recording analytical method (PRAM) (MostCare; Vytech Health srl, Padova, Italy) allows radial artery monitoring of CO, SV, SV variation, and cardiac cycle efficiency (CCE). The authors investigated the hypothesis that NPV improves PRAM-based hemodynamics and arterial blood gas analysis in extubated cardiac surgery patients. DESIGN: A clinical investigation. SETTING: A teaching hospital. PARTICIPANTS: Twenty recently extubated cardiac surgery patients. INTERVENTIONS: Five consecutive experimental ventilation modalities lasted 5 minutes: (1) baseline (no cuirass ventilation), (2) mode 1 (cuirass ventilation with a continuous negative pressure of -20 cmH(2)O), (3) rest 1 (no cuirass ventilation), (4) mode 2 (cuirass ventilation in the control mode of 12 breaths/min at -20 cmH(2)O, and (5) rest 2. MEASUREMENTS AND MAIN RESULTS: PRAM parameters were analyzed throughout the final minute of each experimental modality, concluding with arterial blood gas sampling. NPV was well tolerated. HR was unchanged. Mode 2 SV was higher than baseline and rest 2. Mode 2 CO was higher than rest 2. Rest 2 systolic blood pressure was lower than rest 1 and mode 2. Increased CCE with NPV was not significant (p = 0.0696). Oxygenation and PCO(2) were unchanged although mode 2 pH increased. CONCLUSIONS: Extubated sedated cardiac surgery patients comfortably tolerated NPV with unchanged HR. SV and pH increased.

Assessment of a continuous blood gas monitoring system in animals during circulatory stress.

BACKGROUND: The study was aimed to determine the measurement accuracy of The CDI™ blood parameter monitoring system 500 (Terumo Cardiovascular Systems Corporation, Ann Arbor MI) in the real-time continuous measurement of arterial blood gases under different cardiocirculatory stress conditions METHODS: Inotropic stimulation (Dobutamine 2.5 and 5 µg/kg/min), vasoconstriction (Arginine-vasopressin 4, 8 and 16 IU/h), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in ten swine (57.4 ± 10.7 Kg).Intermittent blood gas assessments were carried out using a routine gas analyzer at any experimental phase and compared with values obtained at the same time settings during continuous monitoring with CDI™ 500 system. The Bland-Altman analysis was employed. RESULTS: Bias and precision for pO2 were - 0.06 kPa and 0.22 kPa, respectively (r2 = 0.96); pCO2 - 0.02 kPa and 0.15 kPa, respectively; pH -0.001 and 0.01 units, respectively ( r2 = 0.96). The analysis showed very good agreement for SO2 (bias 0.04,precision 0.33, r2 = 0.95), Base excess (bias 0.04,precision 0.28, r2 = 0.98), HCO3 (bias 0.05,precision 0.62, r2 = 0.92),hemoglobin (bias 0.02,precision 0.23, r2 = 0.96) and K+ (bias 0.02, precision 0.27, r2 = 0.93). The sensor was reliable throughout the experiment during hemodynamic variations. CONCLUSIONS: Continuous blood gas analysis with the CDI™ 500 system was reliable and it might represent a new useful tool to accurately and timely monitor gas exchange in critically ill patients. Nonetheless, our findings need to be confirmed by larger studies to prove its reliability in the clinical setting.

Multivessel Disease Patients' Outcome and Second Generation Stent: Is Syntax Still a Valid Score? A Real-World Study from a Tertiary Center.

OBJECTIVE: The SYNTAX trial was designed to evaluate whether multivessel disease patients could benefit from percutaneous or surgical revascularization using a paclitaxel eluting stents, but after the introduction of second generation stents, this score needs to be reevaluated. The aim of our study was to analyze the association between SYNTAX score and the prognosis of multivessel patients submitted to percutaneous coronary intervention (PCI) and second generation everolimus eluting stents (EES) implantation. MATERIALS AND METHODS: Data on 289 patients with multivessel coronary artery disease submitted to PCI with EES were stored in a dedicated database and retrospectively analyzed. During a mean follow-up period of 14.4±6.4 months, major adverse cardiac and cerebrovascular events (MACCE) including death from any cause, myocardial infarction, target lesion revascularization (TLR) and stroke, were systematically assessed. RESULTS: The incidence of MACCE at follow-up was 13.1%; death from any cause occurred in 19 patients (6.6%) and myocardial infarction in 9 patients (3.1%). TLR was detected in 2.7% of patients and stroke was observed in 2 patients. The SYNTAX score did not prove to be an independent predictor of overall death at multivariable analysis. CONCLUSION: At mid-term follow-up, the incidence of MACCE in multivessel disease patients submitted to PCI and EES implantation was low; no significant association was found between SYNTAX score severity and MACCE at follow-up, suggesting that it should be modified after the introduction of EES.

Six-month prognostic impact of hemodynamic profiling by short minimally invasive monitoring after cardiac surgery.

Introduction: Studies have shown that a hemodynamic-guided therapy improves the post operative outcomes of high-risk patients.This study, evaluated if a short period through minimally invasive hemodynamic monitoring, pressure recording analytical method (PRAM), on admission to a post-cardiac surgery step-down unit (SDU), may identify patients at higher risk of 6-month adverse events after cardiac surgery. Methods: From December 2016-May 2017,173 patients were admitted in SDU within 24-48 hours of major cardiac surgery procedure, and submitted to clinical, laboratoristic and echocardiographic evaluation and a 1-hour PRAM recording to obtain a "biohumoral snapshot" of individual patient's.156 173 patients (17 patients were lost at follow-up) were phone interviewed six months after surgery,to evaluate, as a composite end-point, the adverse events during follow-up. A multivariable logistic regression analysis was used to identify a model clinical-biohumoral (CBM) and clinical-biohumoral hemodynamics (CBHM). Results: No data from past clinical history and no conventional risk score (EuroScore II, STS score)independently predicted the risk of 6-month major events in our study. The risk of adverse events at six-month follow-up was directly related, in the CBM, to sustained post-operative cardiac arrhythmias, higher values of NT-proBNP and of arterial pH; inversely related to values of hs-C-reactive protein (hs-CRP) and, in the CBHM, to low values of cardiac cycle efficiency (CCE) and dP/dtmax. Conclusion: Our study although limited by its observational nature and by the limited number of patients enrolled, showed that a short period of minimally invasive hemodynamic monitoring increased the accuracy to identify patients at major risk of mid-term events after cardiac surgery.

Vulnerable struts with CRE8, Biomatrix and Xience stents assessed with OCT and their correlation with clinical variables at 6-month follow-up: the CREBX-OCT study.

First-generation drug eluting stents (DES) reduced the incidence of restenosis and need for repeated target lesion revascularization but, in autoptic studies, frequently resulted in incomplete endothelial coverage, which is an important predictor of late adverse events and increased mortality after stent implantation. More recently, not only uncovered, but also malapposed or protruding struts have been considered vulnerable structures, as they are deemed to perturb blood flow, whereas only struts well embedded into the vessel wall are considered stable. We compared the number of uncovered and of other vulnerable (protruding or malapposed) struts among three different second-generation drug-eluting stents (DES) (Cre8, Biomatrix, Xience), using optical coherence tomography (OCT) 6 months after implantation. Moreover, we analyzed the relationship between the percentage of vulnerable struts and the clinical characteristics of patients. 60 patients with stable angina or non-ST-Elevation acute coronary syndrome and indication to percutaneous angioplasty were randomly assigned to receive one of the three DES. After 6 months, OCT images were obtained. After 6 months, OCT images were obtained (1289 cross sections; 10,728 struts). None of the three DES showed non-coated struts or areas of stent thrombosis. Significant differences in the average number of protruding struts (Cre8: 33.9 ± 12.6; Biomatrix: 26.2 ± 18.1; Xience: 13.2 ± 8.5; p < 0.001) and in the proportion of malapposed struts (Cre8: 0.7%; Biomatrix: 0.9%; Xience: 0.0%; p = 0.040) and of incomplete stent apposition area (Cre8: 10.4%; Biomatrix: 4.7%; Xience: 0.7%; p < 0.001) were observed. No significant difference was found in neointimal hyperplasia area with a not significant tendency toward greater minimal and maximal struts thickness for Biomatrix. In comparison with Cre8 and Biomatrix, Xience showed a significantly lower proportion of vulnerable struts in all clinical sub-groups considered. In the group of 60 patients a significant relation was found between age and number of vulnerable struts (p = 0.014). The three second-generation DES were similarly effective in permitting neo-intimal formation and complete struts coating 6 months after implantation, but Cre8 and Biomatrix showed a greater proportion of protruding and malapposed struts.Trail Registry: Clinical Trials.gov Identifier: NCT02850497.

Deep sedation vs femoral block anesthesia: beat-by-beat hemodynamic impact on TAVI procedure.

BACKGROUND: In spite of the increased use of Trans-catheter Aortic Valve Implantation (TAVI) due to the better patient selection, well-trained operators and improved technology, the choice of the best anesthesia regimen remains an open question. In particular, it remains to be clarified whether deep sedation (DS) in spontaneous breathing or femoral local anesthesia (LA) is best. OBJECTIVE: This study compared the hemodynamic variations determined by deep sedation (DS) with spontaneous breathing and local femoral anesthesia (LA) in 2 groups of patients submitted to TAVI with two different kinds of anesthesia, using a beat-by-beat pulse contour method (MostCare®-UP). METHODS: 82 patients with severe aortic stenosis and similar baseline characteristics and indications underwent trans-femoral TAVI: 50 with LA and 32 with DS. All patients were submitted to minimally invasive hemodynamic monitoring. The following parameters were measured: pressure indexes: systolic, diastolic, mean (SysP, DiaP, MAP) and dicrotic (DicP) pressures; flow indexes: cardiac output (CO), stroke volume (SV); ventriculo-arterial coupling indexes (VAC): peripheral arterial elastance (EaP), systemic vascular resistance (SVR); cardiovascular system performance: cardiac cycle efficiency (CCE), dP/dtmax_rad. RESULTS: The TAVI procedure was successful in 89% of patients (VARC-2 criteria) with no difference between the 2 groups. Anesthesia induction determined a higher decrease of pressures in DS than in LA (P<0.01) with no differences in CO. The VAC parameters (EaP, SVR) decreased (P<0.01) in DS with an improvement in CCE (P<0.001); these parameters did not change in LA. The post-TAVI flow and VAC parameters, especially Ea, increased (P<0.05) more significantly in the LA group than in the DS group (P<0.001). Using logistic regression, the occurrence of the post-TAVI aortic regurgitation was correctly associated with the pressure gradient MAP-DicP in 63% of the study population (P=0.033). This association was more effectively detected in the LA group (78%, P=0.011) with a ROC AUC=0.779, than the DS group. CONCLUSION: The use of the pulse contour method to track the fast-hemodynamic changes during the TAVI procedure proved suitable for the aim. As expected, LA and DS induced different pre-TAVI hemodynamic conditions, which influenced the post-TAVI hemodynamic changes. The hemodynamic conditions induced by LA, enabled the occurrence of post-TAVI aortic regurgitation to be detected more effectively.

Response of serum proteome in patients undergoing infrarenal aortic aneurysm repair.

BACKGROUND: Postoperative organ dysfunction in conventional surgery for abdominal aortic aneurysm (AAA) is associated with a complex inflammatory reaction, with activation of coagulation and fibrinolysis. A prospective,observational study was performed to define the complex plasma proteomic changes after AAA repair and to identify factor(s) that may affect myocardial function in uncomplicated procedures. METHODS: Ten patients undergoing infrarenal AAA repair were investigated. Eight subjects subjected to major abdominal surgery served as controls. Hemodynamic changes were continuously monitored by using the pressure recording analytical method technique. The time course of plasma proteins was investigated after induction of anesthesia and at different times after surgery (6 h, 12 h, 24 h, 36 h) by using two-dimensional difference gel electrophoresis, matrix-assisted laser desorption/ionization-time of flight mass spectrometry, and Western blot. The effects of plasma on the functional properties of isolated rat ventricular myocytes were also investigated. RESULTS: In AAA patients alone, 18 spots were found to change more than two-fold in expression level, spot identification revealing an increased thrombin generation 6 h after surgery. At the same time cardiac cycle efficiency significantly reduced versus baseline (-0.5 +/- 0.9 vs. 0.18 +/- 0.3 in AAA patients, P < 0.01; 0.4 +/- 0.1 vs. 0.2 +/- 0.3 in control surgery, not significant; P < 0.01 group x time interaction at ANOVA). Plasma obtained 6 h after AAA surgery dose-dependently inhibited contractile function of control rat myocytes (percent shortening fell by 51% with 10% of AAA plasma and was abolished with 20% of AAA plasma, P < 0.001 for both). The inhibitory response was abolished by thrombin antagonism. CONCLUSIONS: These findings show for the first time the possible role of thrombin generation within the complex activation of inflammatory response in causing hemodynamic instability in the early postoperative period after AAA surgery.

Hemodynamic monitoring by pulse contour analysis during trans-catheter aortic valve replacement: A fast and easy method to optimize procedure results.

BACKGROUND: Residual aortic regurgitation (AR) complicates a not negligible number of transcatheter aortic valve replacement (TAVR) procedures, and its entity is not always clear at intraprocedural angiographic and echocardiographic control. We applied a minimally invasive hemodynamic monitoring system (Pressure Recording Analytical Method, PRAM) in the setting of TAVR, with the aim of identifying parameters that may help in detection and quantification of residual AR. METHODS: We performed hemodynamic monitoring with PRAM in 43 patients undergoing trans-femoral TAVR. Investigated parameters were systolic (Psys, mm Hg), diastolic (Pdia, mm Hg), mean (MAP, mm Hg) and dicrotic pressure (Pdic, mm Hg), cardiac output (CO, L/min), stroke volume (SV, mL), cardiac cycle efficiency (CCE, Units), dP/dtmax_rad (mm Hg/ms), MAP-Pdic (mm Hg). RESULTS: Procedural success was achieved in 86% of the patients; vascular complications occurred in 3 (6.9%), death in 2 (4.7%). Twenty (46.5%) patients had at least mild residual AR. CO, SV, CCE and dP/dtmax_rad changed significantly (p < 0.001) between baseline and end of procedure in the overall population, with more evident modifications in the subgroup without residual AR. MAP-Pdic variations were statistically significant only in the subgroup without AR (p = 0.05). CONCLUSIONS: TAVR determined an improvement in hemodynamic parameters such as CO, SV, CCE, dP/dtmax_rad. MAP-Pdic was able to discriminate patients with significant residual AR. Hemodynamic monitoring with PRAM system during TAVR is easy and fast to obtain and may help in clinical decision-making in controversial cases.

Continuous hemodynamic monitoring during laparoscopic gastric bypass in superobese patients by pressure recording analytical method.

BACKGROUND: Morbid obesity, compromising cardiovascular and respiratory function, may increase the risk of anesthesia and was initially considered a contraindication to laparoscopy. The aim of this study was to investigate hemodynamic effects induced by pneumoperitoneum in superobese patients, assessed by arterial pulse contour method. METHODS: We prospectively studied 10 obese patients (BMI 53 +/- 9 kg/m(2)), scheduled for laparoscopic gastric bypass. After anesthesia induction, patients were intubated and mechanically ventilated. A radial artery was cannulated to obtain hemodynamic data implemented by means of a new pulse contour analysis method-the pressure recording analytical method (PRAM). Data were recorded after anesthesia induction (Tbas), at peritoneal insufflation (T0), at 1, 3, 5, 10, 30, and 60 min after pneumoperitoneum induction (T1, T3, T5, T10, T15, T30, T60), at abdominal desufflation (Tdef) and 5 min after desufflation (T5def). RESULTS: MAP increased after pneumoperitoneum, returning to its baseline after deflation (79 +/- 7 Tbas, 81 +/- 6 mmHg T5def). HR remained unchanged. Systemic vascular resistance index (SVRI) increased after pneumoperitoneum induction and progressively returned to baseline (3,903 +/- 330 Tbas, 4,596 +/- 148 T1, and 3,786 +/- 202 dyn s m(2) cm(-5) T5def). Stroke volume index (SVI) and cardiac index (CI) increased after pneumoperitoneum and remained elevated. Stroke volume variation (SVV) decreased after insufflation remaining lower than the basal value (28 +/- 4% Tbas, 15 +/- 5% T5des). Cardiac Cycle Efficiency (CCE) transient decreased after insufflation and subsequently increased (0.029 +/- 0.146 Tbas, 0.008 +/- 0.178 T5def). Aortic dP/dt max increased after insufflation, returning to baseline only after desufflation (0.68 +/- 0.07 Tbas, 0.94 +/- 0.08 T30 and 0.86 +/- 0.06 mmHg s(-1) T5def). CONCLUSION: As assessed by PRAM, this study showed no deterioration in hemodynamic indices or ventricular performance during laparoscopic gastric bypass.

Timing, setting and incidence of cardiovascular complications in patients with acute myocardial infarction submitted to primary percutaneous coronary intervention.

BACKGROUND: At the Istituto di Clinica Medica Generale e Cardiologia (Florence, Italy), the widespread use of percutaneous coronary intervention (PCI) has markedly changed the hospital course of patients with acute myocardial infarction (AMI). These patients are typically transferred to the coronary care unit (CCU) only after primary PCI, whereas during the thrombolytic era, patients were first admitted to CCU before reperfusion. OBJECTIVES AND METHODS: The incidence, timing and setting of complications from symptom onset to hospital discharge in 689 consecutive AMI patients undergoing PCI were evaluated. RESULTS: Ventricular fibrillation occurred in 11% of patients, and most episodes (94.7%) occurred before or during PCI. Of all patients, 6.3% developed complete atrioventricular block (CAVB), and in 86.3% of these cases, the CAVB occurred before or during PCI; in 94.5%, a CAVB resolution occurred in the catheterization laboratory (CL). Thirty-one patients (4.5%) had impending shock on admission to the CL. Cardiogenic shock developed in 2 9 patients (4.2%), mostly in the prehospital phase or in the CL. Only four patients (less than 1%) developed cardiogenic shock later during their hospital course. Similarly, circulatory and ventilatory support, as well as temporary pacing and cardiac defibrillation, were used mostly in the prehospital phase or in the CL. During the CCU stay, 45 patients (6.5%) had hemorrhagic or vascular complications, and the incidence of post-PCI ischemia and early reocclusion of the culprit vessel were low (2.1% and 0.6%, respectively). Thus, cardiac complications usually associated with AMI were observed mainly before hospital admission or in the CL during the reopening of the target vessel. These complications were rarely observed after a successful PCI. CONCLUSIONS: For AMI patients, the CL is not only the site of PCI, it is also where most life-threatening cardiac complications are observed and treated.

COmparison between COronary THrombus aspiration with Angiojet® or Export® catheter in patients with ST-elevation myocardial infarction submitted to primary angioplasty: The COCOTH Study.

AIMS: To compare the effects of two thrombus aspiration devices, the manual catheter Export® and the more complex and expensive mechanical Angiojet®, on several indices of reperfusion in acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Clinical, hemodynamic and procedural characteristics of 185 STEMI patients, randomized to treatment with Export (n=95) or Angiojet (n=90) during primary percutaneous coronary intervention (PPCI) were analyzed. The primary endpoint was ST-segment elevation reduction 90 min after culprit vessel re-opening. Secondary endpoints included variations in some angiographic parameters (TIMI Flow, TIMI Frame Count and Myocardial Blush Grade) and Infarct Size and Severity at myocardial scintigraphy. A significant reduction in ST-elevation was observed in both groups after PPCI without significant differences between the two groups. No significant difference between Angiojet vs. Export was observed in ST-segment resolution >50% and ≥ 70%, in TIMI Flow, TIMI Frame Count and Myocardial Blush Grade before vs. after PPCI and in Infarct Size and Severity. CONCLUSIONS: PPCI with thrombus aspiration was effective in both groups of patients, without differences in myocardial reperfusion and necrosis indices. These results could support the routine use of manual devices during PPCI, reserving the more expensive Angiojet in case of manual device failure and persistent or massive intracoronary thrombosis, with favorable implications in terms of cost containment.

A New 35-mm Short Intra-aortic Balloon Catheter: A Suitable Option Also for Non-Small-Sized Patients?

OBJECTIVE: Visceral ischemia can be a potentially life-threatening complication of intra-aortic balloon pump (IABP) support. A shorter IABP catheter might lead to a reduction of visceral complications. In this animal study, we evaluate the effects of a 35-mL short catheter in comparison with a 40-mL standard-sized catheter. METHODS: Eighteen healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion being supported by either a short IABP catheter (short group) (n = 6) or a long IABP catheter (long group) (n = 6) or with no assistance (controls) (n = 6). Hemodynamics, visceral and coronary flows, as well as biochemical markers were evaluated throughout the different phases of the protocol. RESULTS: Mesenteric flows increased significantly at reperfusion (P < 0.001 both) remaining constant afterward (all, P > 0.05) in the short group, while remaining significantly lower in the long group at the start of reperfusion, remaining constantly lower than the short group and controls (P < 0.001 vs short, P < 0.003 vs controls). In both long and short groups, catheters improved renal flows at reperfusion (P < 0.001 both) without any further variation (P > 0.05). In the short group, the flows were higher during the whole of reperfusion (all, P < 0.05). Intra-aortic balloon pump support improved hemodynamic indices and coronary blood flows during reperfusion to a similar extent in both the small and the long group (P > 0.05). CONCLUSIONS: The short IABP catheter proved to be as effective as the standard-sized catheter in supporting hemodynamics and coronary circulation. Furthermore, it even improves visceral flows in comparison with conventional IABP catheters.