Factors Affecting Platelet Reactivity 2 Hours After P2Y12 Receptor Antagonist Loading in Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction - Impact of Pain-to-Loading Time.

BACKGROUND: Delay in the onset of antiplatelet action occurs in patients with ST-elevation myocardial infarction (STEMI) and is likely due to disturbed absorption. We hypothesized that patients presenting relatively late after the onset of symptoms would have faster antiplatelet action. METHODS AND RESULTS: We analyzed patient-level data from 5 studies of 207 P2Y12 receptor antagonist-naïve patients with STEMI undergoing primary percutaneous coronary intervention (PCI). All patients had available platelet reactivity (PR) assessment with the VerifyNow assay (in P2Y12 reaction units; PRU) prior to and 2 h after loading. High PR (HPR) was defined as ≥ 208 PRU. Pain-to-antiplatelet loading time independently predicted PR at 2 h after loading: every 1-h increase in pain-to-antiplatelet loading time produced a 7% decrease in PR (P=0.001). Pretreatment PR, body mass index, morphine and novel P2Y12 receptor antagonist also affected PR 2 h after loading. Novel P2Y12 receptor antagonist use and per hour increase in pain-to-antiplatelet loading time were independently associated with lower probability for HPR with an OR (95% CI) of 0.145 (0.095-0.220) and 0.776 (0.689-0.873), P<0.001 for both (C-statistic, 0.752; 95% CI: 0.685-0.819). CONCLUSIONS: In STEMI patients undergoing primary PCI, pain-to-antiplatelet loading interval is a newly described factor affecting PR shortly after P2Y12 receptor antagonist loading, according to patient-level data pooled analysis.

Ticagrelor vs clopidogrel followed by ticagrelor re-loading in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A randomized, pharmacodynamic comparison.

Among patients allocated to ticagrelor in the primary percutaneous coronary intervention (PCI) cohort of Platelet Inhibition and Patient Outcomes (PLATO) trial, 40.7% had received pre-randomization 600 mg of clopidogrel. This scenario is frequently employed in real-world practice. In a prospective, three-center, single-blind, parallel design study, 74 P2Y12 inhibitor-naive patients undergoing primary PCI were randomized (Hour 0) to ticagrelor 180 mg loading dose (LD) vs clopidogrel 600 mg LD followed after 2 h by ticagrelor 180 mg re-LD. Platelet reactivity (VerifyNow, in PRU) was assessed at Hour 0, 2, 4, 6, and 24. The primary comparison was non-inferiority of ticagrelor to clopidogrel followed by ticagrelor re-LD regarding platelet reactivity at 24 h using a prespecified margin of <35 PRU for the upper bound of the one-sided 97.5% confidence interval (CI). Ticagrelor was proven non-inferior to clopidogrel followed by ticagrelor re-LD with a difference between arms of 13.5 PRU (28.8 upper 97.5% CI), p = 0.001. At Hour 2, platelet reactivity was lower in ticagrelor only vs clopidogrel followed by ticagrelor re-LD groups with least square estimate mean difference (95% CI) -105.7 (-140.6 to -70.8), p < 0.001, without significant difference thereafter. In conclusion, in patients undergoing primary PCI, a strategy of ticagrelor LD only was proven non-inferior to clopidogrel LD followed by ticagrelor re-LD, in terms of antiplatelet efficacy at 24 h post-randomization and provided an earlier onset of platelet inhibition.

Left bundle branch area pacing versus conventional pacing in patients with advanced atrioventricular conduction abnormalities: a prospective cohort study.

BACKGROUND: Left bundle branch area pacing (LBBAP) is an emerging pacing method that may prevent the deleterious effects of right ventricular pacing. The aim of this study is to compare the effects of LBBAP with right ventricular septal pacing (RVSP) in patients with advanced atrioventricular conduction abnormalities and preserved left ventricular ejection fraction. METHODS: The effect of pacing was evaluated by echocardiographic indices of dyssynchrony, including global myocardial work efficiency (GWE) and peak systolic dispersion (PSD). The primary endpoint was GWE postprocedural, at 3, 6, and 12 months after the procedure. RESULTS: Twenty patients received LBBAP and 18 RVSP. Complete follow-up was accomplished in 37 patients (97.4%) due to the death of a patient (RVSP arm) from nonrelated cause. GWE was significantly increased in the group of LBBAP compared to RVSP at all time points (90.8% in LBBAP versus 85.8% in RVSP group at 12 months, p = 0.01). PSD was numerically lower in the LBBAP arm at all time points, yet not statistically significant (56.4 msec in LBBP versus 65.1 msec in RVSP arm at 12 months, p = 0.178). The implantation time was increased (median 93 min in LBBAP versus 45 min in RVSP group, p < 0.01), along with fluoroscopy time and dose area product (DAP), in the arm of LBBAP. There were no severe perioperative acute complications in either group. CONCLUSIONS: LBBAP is an emerging and safe technique for patients with a pacing indication. Despite the longer procedural and fluoroscopy time, as well as higher DAP, LBBAP seems to offer better left ventricular synchrony compared to RVSP, according to GWE measurements.

Facilitating assessment of QT interval duration during ventricular pacing.

AIMS: We aimed to facilitate the assessment of the QT interval duration during conventional right ventricular pacing (VP) by uncovering relationships with the underlying QT interval during intrinsic atrioventricular conduction (IC). METHODS AND RESULTS: The study patients (n = 122, age 68 ± 11 years) were dual-chamber device recipients with preserved IC and narrow QRS complexes. Patients were classified into either 'normal-QT' (n = 70) or 'prolonged-QT' (n = 52) group. Incremental atrial pacing rates were exercised to record serial QT/JT intervals over 5 min periods in IC mode and then in VP mode. Six different QT correction methods for heart rate were applied to assess the effect (i) of pacing mode (IC vs. VP) and (ii) of heart rate on the derived QT(c)/JT(c) intervals by mixed-effects linear models. Following VP, the uncorrected QT/JT intervals as well as the JTc intervals shortened (P < 0.001), whereas the QTc intervals prolonged (P < 0.001). In both patient groups, the Framingham and Nomogram methods demonstrated the optimal balance to assess QTc, with low heart rate dependence during VP and minimal interaction between pacing mode and heart rate. The Rautaharju formula provided excellent correction for the QT changes induced by VP, but the QTc interval responded differently to rate changes in IC vs. VP mode. Bazett's formula exaggerated QTc/JTc rate dependency during VP. CONCLUSION: The Framingham and Nomogram correction methods perform most reliably in assessing the underlying QT interval during IC from the ventricular paced QT interval.

Myasthenia Gravis and Abdominal Aortic Aneurysm: A Rare Combination.

Abdominal aortic aneurysm in a patient with myasthenia gravis (MG) is extremely rare. We present a 64-year-old male with MG and an asymptomatic abdominal aortic aneurysm treated endovascularly. After extubation, he suffered a cardiac arrest due to an acute myocardial infarction. Cardiopulmonary resuscitation and a primary coronary angioplasty led to a satisfactory outcome. Special care is needed due to higher rates of postoperative complications in these patients.

Predicting torsade de pointes in acquired long QT syndrome: optimal identification of critical QT interval prolongation.

OBJECTIVES: To determine the optimal method of ventricular repolarization assessment in predicting torsade de pointes (Tdp) in acquired long QT syndrome (LQTS) within the context of the recommended cutoff levels of concern for QT/corrected QT (QTc) interval prolongation. METHODS: Twenty-nine patients with LQTS and Tdp (age 66 ± 11 years) and matched controls were studied. Standard 12-lead electrocardiograms were utilized to evaluate ventricular repolarization by using six different QT/JT heart rate correction methods. We compared the distribution of QT/QTc and JT/corrected JT intervals of patients who experienced Tdp with (1) the corresponding intervals in the matched controls and (2) the recommended cutoff levels for QT/JT interval prolongation. RESULTS: Patients with Tdp (23 with narrow QRS, 6 with wide QRS) had longer ventricular repolarization intervals than controls (p < 0.001). For patients with narrow QRS, the QTc interval as determined firstly by the method of Hodges (t = 7.56, c = 0.933, p < 0.001), followed by the Nomogram and Fridericia methods, best discriminated Tdp patients from controls and provided the optimal balance between sensitivity and specificity at all three cutoff levels. For patients with wide QRS, the JT interval or, alternatively, the Hodges method seemed most useful. CONCLUSIONS: Assessment of ventricular repolarization by the Hodges, Nomogram and Fridericia methods performs best in identifying subsequent Tdp.

Optimal QT/JT interval assessment in patients with complete bundle branch block.

BACKGROUND: Prolonged ventricular repolarization duration confers increased risk for malignant ventricular arrhythmias. We sought to clarify the optimal method of QT/JT interval assessment in patients with complete bundle branch block (BBB). METHODS: Study patients (n = 71) were dual-chamber device recipients with baseline left or right BBB who preserved intrinsic ventricular activation during incremental atrial pacing. Patients were classified according to the presence or not of structural heart disease. The former group received chronic amiodarone therapy. QT and JT intervals were recorded at baseline heart rate of 51 ± 4 beats/min and during atrial pacing at 60, 80, and 100 beats/min. We used linear mixed-effects models to assess the effect of heart rate on the derived QTc and JTc values with the use of six different heart rate correction formulae. RESULTS: Heart rate had a significant effect on the QTc and the JTc intervals regardless of the correction formula used (P < 0.001 for all formulae). The formula of Hodges demonstrated the least variability in QTc and JTc measurements across the different heart rates in both patients groups without (F = 15.05 and F = 13.53, respectively) and with structural heart disease (F = 5.71 and F = 7.69, respectively), followed by the Nomogram and Framingham methods, whereas the uncorrected QT and JT intervals showed comparable heart rate-dependency. The application of Bazett's JTc and QTc led to the most pronounced interval variations in any case with BBB. CONCLUSIONS: The Hodges, Nomogram and Framingham correction methods provide best assessment of QT/JT intervals in BBB, whereas Bazett's formula exaggerates heart rate-dependency of ventricular repolarization intervals.

A case report of surgical repair of a post-catheterization radial pseudoaneurysm.

We report an 83-year-old patient with a huge post-catheterization right radial pseudoaneurysm, presented 17 months after a coronary angiography. Cases of radial post-catheterization pseudoaneurysms with a similar size are scarce in the literature. Delay in presentation led to painful skin ischemia due to tension, a sign of imminent rupture, which is also rare in the literature. Symptomatology included severe wrist pain and clinical signs consisted of a pulsatile painful mass in the right distal forearm. Management consisted of surgical excision and ligation of the radial artery in an urgent base. This case emphasizes the need for early diagnosis and management of post-catheterization pseudoaneurysms as delay may lead to severe enlargement with skin necrosis and imminent rupture. Ligation of the radial artery is an acceptable option when reconstruction of the artery is troublesome, provided that the palmar arch remains patent.

Preferred QT correction formula for the assessment of drug-induced QT interval prolongation.

INTRODUCTION: There is debate on the optimal QT correction method to determine the degree of the drug-induced QT interval prolongation in relation to heart rate (DeltaQTc). METHODS: Forty-one patients (71 +/- 10 years) without significant heart disease who had baseline normal QT interval with narrow QRS complexes and had been implanted with dual-chamber pacemakers were subsequently started on antiarrhythmic drug therapy. The QTc formulas of Bazett, Fridericia, Framingham, Hodges, and Nomogram were applied to assess the effect of heart rate (baseline, atrial pacing at 60 beats/min, 80 beats/min, and 100 beats/min) on the derived DeltaQTc (QTc before and during antiarrhythmic therapy). RESULTS: Drug treatment reduced the heart rate (P < 0.001) and increased the QT interval (P < 0.001). The heart rate increase shortened the QT interval (P < 0.001) and prolonged the QTc interval (P < 0.001) by the use of all correction formulas before and during antiarrhythmic therapy. All formulas gave at 60 beats/min similar DeltaQTc of 43 +/- 28 ms. At heart rates slower than 60 beats/min, the Bazett and Framingham methods provided the most underestimated DeltaQTc values (14 +/- 32 ms and 18 +/- 34 ms, respectively). At heart rates faster than 60 beats/min, the Bazett and Fridericia methods yielded the most overestimated DeltaQTc values, whereas the other 3 formulas gave similar DeltaQTc increases of 32 +/- 28 ms. CONCLUSIONS: Bazett's formula should be avoided to assess DeltaQTc at heart rates distant from 60 beats/min. The Hodges formula followed by the Nomogram method seem most appropriate in assessing DeltaQTc.

Heart rate-dependence of QTc intervals assessed by different correction methods in patients with normal or prolonged repolarization.

BACKGROUND: There is a continuing debate about the optimal method for QT interval adjustment to heart rate changes. We evaluated the heart rate dependence of QTc intervals derived from five different QT correction methods. METHODS: Study patients (n = 123, age 68 +/- 11 years) were dual-chamber device recipients with baseline normal or prolonged QT interval who had preserved intrinsic ventricular activation with narrow QRS complexes. Patients were classified to either Normal-QT (n = 69) or Prolonged-QT (n = 54) groups. Serial QT intervals were recorded at baseline (52 +/- 3 beats per minute) and following atrial pacing stages at 60, 80, and 100 beats per minute. The QTc formulae of Bazett, Fridericia, Sagie-Framingham, Hodges, and Karjalainen-Nomogram were applied to assess the effect of heart rate on the derived QTc values by using linear mixed-effects models. RESULTS: Heart rate had a significant effect on QTc regardless of the formula used (P < 0.05 for all formulae). The Bazett's formula demonstrated the highest QTc variability across heart rate stages (highest F values) in both patient groups (in the total cohort, F = 175.9). In the following rank order, the formulae Hodges, Karjalainen-Nomogram, Sagie-Framingham, and Fridericia showed similar QTc heart rate dependence at both slower and faster heart rates in both patient groups (F = 21.8, 25.6, 28.8, 36.9, in the total cohort, respectively). CONCLUSIONS: Of the studied QTc formulae, the Bazett appeared the most heart rate dependent. Our results suggest the use of Hodges and the Karjalainen-Nomogram secondly to ensure least heart rate dependence of QTc intervals in patients with either normal or prolonged repolarization.

Outcome of patients with acute myocardial infarction admitted in hospitals with or without catheterization laboratory: results from the HELIOS registry.

AIMS: To compare the treatment and outcomes of myocardial infarction patients in hospitals with and without catheterization laboratory. METHODS AND RESULTS: The Hellenic Infarction Observation Study was a countrywide registry of acute myocardial infarction, conducted during 2005-2006. The registry enrolled 1840 patients with myocardial infarction from 31 hospitals with a proportional representation of all types of hospitals and of all geographical areas. Out of these patients, 645 (35%) were admitted in 11 hospitals with and 1195 (65%) in 20 hospitals without catheterization laboratory. Patients admitted in hospitals with catheterization laboratory in comparison with patients admitted in hospitals without were younger (66+/-14 vs. 68+/-13, P<0.004) with less diabetes (27 vs. 33%, P<0.001), but without other baseline differences (female 27 vs. 25%, prior myocardial infarction 20 vs. 17%, Killip class>1 22 vs. 23%). Reperfusion rates for ST-segment elevation myocardial infarction were 67% (43% lytic, 24% primary percutaneous coronary interventions) versus 56% (55% lytic, 1% percutaneous coronary interventions; P<0.01). In-hospital outcomes in hospitals with versus in hospitals without laboratory were: mortality 6.5 versus 8.3% (NS), stroke 2.2 versus 1.1% (NS), major bleeding 1.1 versus 0.6% (NS), and heart failure 11 versus 16% (P<0.01). In multivariate regression analysis, being admitted in a hospital without catheterization laboratory was not an independent predictor of increased in-hospital mortality (odds ratio=1.18, 95% confidence interval: 0.72-1.93, P=0.505). CONCLUSION: Although the majority of acute myocardial infarction patients was admitted in hospitals without catheterization laboratory, these patients do not have a survival disadvantage, provided they are treated with lytic therapy, medical secondary prevention drugs, and eventual revascularization according to current guidelines.

A Case of Serratia marcescens Endocarditis in a Nonintravenous Drug-Using Male Patient and Review of Literature.

INTRODUCTION: Serratia marcescens is a rare cause of infective endocarditis and has almost exclusively been associated with intravenous drug use and hospital-acquired infections. Here, we present a case of infective endocarditis caused by Serratia marcescens in an otherwise healthy, nonintravenous drug-using male patient. CASE REPORT: A 41-year-old man presented with hypertension and hemoptysis. Blood cultures were obtained that showed bacteremia by Serratia marcescens. An echocardiogram was carried out that revealed severe mitral regurgitation accompanying ruptured mitral chordae tendineae. The patient received the appropriate antibiotic treatment, without further surgical intervention. DISCUSSION: Hospital-acquired infections by Serratia species are a common problem in medical practice and have been attributed to specialized interventional procedures. Taking into consideration the patient's immunocompetence and lack of intravenous drug use, it is possible that bacteremia could be attributed to a medical procedure. Moreover, in contrast to most cases described in the literature, no surgery was performed.

Escherichia coli Endocarditis Presenting With Septic Shock in an Immunocompetent Female Patient.

Escherichia coli (E. coli) is a rare cause of infective endocarditis, despite being a common cause of bacteremia. E. coli endocarditis affects most frequently immunocompromised elderly women, especially those with diabetes mellitus. We present a case of a 78-year-old female immunocompetent patient, presenting with septic shock and multiple organ dysfunction syndrome. E. coli was isolated in all sets of blood cultures and in urine culture and a contrast-enhanced abdominal computed tomography (CT) scan revealed spleen and left kidney infracts. Transthoracic echocardiography revealed a large (> 15 mm) mobile mass on the atrial side of the posterior mitral valve leaflet. The patient was initially treated with intravenous ceftriaxone and ciprofloxacin for 2 weeks with successful clinical response and clearance of bacteremia, was then subjected to valve replacement (with isolation of E. coli from replaced valve cultures) and continued antibiotic therapy for additional 4 weeks postoperatively. E. coli has emerged in recent years as an important cause of bacteremia, especially in the elderly. In selected patients, as those with persistent Gram-negative bacteremia or severe sepsis/septic shock, echocardiography is of paramount importance for the diagnosis of Gram-negative endocarditis and should be included in our diagnostic algorithm of patient's evaluation.

Impact of Arteriovenous Fistula on Cardiac Size and Function in Kidney Transplant Recipients: A Retrospective Evaluation of 5-Year Echocardiographic Outcome.

OBJECTIVES: The effect of a functioning arteriovenous fistula on cardiac function in kidney transplant recipients has not been thoroughly investigated. MATERIALS AND METHODS: We retrospectively evaluated cardiac function in 99 renal transplant recipients using transthoracic echocardiography, with available follow-up at baseline and 2 and 5 years posttransplant. Patients were divided into 2 groups: a control group (n = 47) with no functioning arteriovenous fistula immediately after transplant and an arteriovenous fistula group (n = 52) with a functioning arteriovenous fistula for at least 5 years after transplant. Left ventricular ejection fraction, diastolic thickness of the interventricular septum, and left ventricular end-diastolic diameter were assessed. RESULTS: In our study, patients (62.6% men, 7.1% with diabetes, mean age of 55.6 ± 11.5 years), we observed no significant differences with respect to baseline left ventricular ejection fraction and interventricular septum; however, in the arteriovenous fistula group, baseline left ventricular end-diastolic diameter was marginally higher than that shown in the control group (50.6 ± 5.4 vs 48.6 ± 4.4 mm; P = .054). In multivariate analysis, functioning fistula and peripheral arterial disease were negatively associated with left ventricular ejection fraction at 5 years posttransplant, whereas baseline left ventricular ejection fraction had a minimal positive effect: B (95% confidence interval) of -2.186 (-4.312 to -0.061) (P = .044), -5.304 (-9.686 to -0.922) (P = .018), and 0.247 (0.047 to 0.446) (P = .016), respectively. Functioning fistula also emerged as associated with larger left ventricular end-diastolic diameter at 2 and 5 years posttransplant: B (95% confidence interval) of 3.047 (1.470-4.625) (P < .001) and 2.122 (0.406-3.838) (P = .016), respectively. CONCLUSIONS: Maintenance of a functioning fistula in kidney transplant recipients may be associated with adverse long-term effects on left ventricular ejection fraction and left ventricular end-diastolic diameter.

Predischarge QRS score and risk for heart failure after first ST-elevation myocardial infarction.

BACKGROUND: The prognostic value of the QRS score, a simple index of infarct size after a first ST-elevation myocardial infarction, has not been adequately explored in the reperfusion era. METHODS AND RESULTS: We prospectively followed up 100 consecutive survivors of a first ST-elevation myocardial infarction (aged 64 +/- 13 years, 77% were male) without bundle branch block or paced rhythm at hospital discharge for 3 months. The modified 32-point QRS score was calculated as part of the predischarge evaluation. The predefined primary endpoint was the composite of death or hospitalization for heart failure. By 3 months, 6 patients died and 16 patients were readmitted for heart failure, resulting in a 22% primary endpoint rate. Patients with a QRS score >/= 3 at hospital discharge (n = 38) had significantly more events compared with those with a QRS score < 3 (44.7% vs. 8.2%, P < .001), and all six deaths occurred among patients with a QRS score >/= 3 (P = .002). A QRS score < 3 reliably predicted heart-failure free survival during the follow-up period (negative predictive value 91.9%). In multivariate models, the QRS score was an independent predictor of the primary endpoint (hazard ratio = 1.4 per point, 95% confidence interval 1.1-1.8, P = .003). CONCLUSION: For patients surviving a first ST-elevation myocardial infarction, the predischarge QRS score provides powerful prognostic information on short-term outcomes, including mortality and readmission for heart failure.

Transthoracic Doppler echocardiography assessment of left anterior descending artery flow in patients with previous anterior myocardial infarction.

AIM: We tested the hypothesis that shortening of diastolic pressure half time (PHT) of left anterior descending (LAD) coronary flow in patients with old reperfused anterior myocardial infarction (MI) is related to the presence of permanent myocardial damage of the reperfused area. METHODS AND RESULTS: We studied 49 patients divided into: group A: 15 patients with previous anterior MI and evidence of myocardial scar; group B: 10 patients with previous anterior MI and no evidence of myocardial scar and group C: 24 patients without anterior MI. All patients underwent coronary angiography at least 6 months after an index event and any reperfusion procedure. Group A patients had lower PHT (199 +/- 62 ms) than group C (377 +/- 103 ms, p = 0.0001) and group B (316 +/- 154 ms, p = 0.029) patients. No other LAD flow velocity parameter differed among the 3 groups. A PHT value of 265 ms discriminated patients with scarred anterior wall with a sensitivity of 79% and a specificity of 94% (0.88, p < 0.001). CONCLUSION: Shortening of the LAD flow diastolic PHT in patients with remote, reperfused anterior MI reflects scarred myocardial tissue in the anteroapical wall while patients who maintain diastolic wall thickness after an acute coronary syndrome have PHT similar to patients without anterior MI.

Usefulness of rate regulation through continuous ventricular pacing in patients with drug-controlled slower atrial fibrillation and normal or depressed left ventricular systolic function.

We studied 33 clinically stable patients with permanent atrial fibrillation (AF), implanted with a ventricular demand rate-responsive (VVIR) pacemaker or an automatic defibrillator, in order to evaluate whether continuous right ventricular apex pacing (VP) conferring rate regulation may be advantageous when compared with slower drug-controlled AF. Devices were chronically programmed at ventricular backup pacing. Patients were divided in two groups according to their normal (n = 17) or depressed (n = 16) left ventricular systolic function (LVSF). Ventricular function was studied by using tissue Doppler and color M-mode and echocardiography, as well as B-type natriuretic peptide (BNP) measurements. Baseline data during AF were compared to corresponding measurements following a 1-month pacing period after the devices were programmed at a base rate of 70 beats/min. In both groups, VP worsened some indexes of left and right ventricular function (P < 0.05) without significantly affecting cardiac output, left ventricular filling pressures and BNP (P = not significant). We conclude that VP should not be considered advantageous compared to slower AF.

Adverse effects of continuous ventricular pacing in patients with slower atrial fibrillation and normal left ventricular systolic function.

BACKGROUND: Both heart rate irregularity during chronic atrial fibrillation (AF) and ventricular desynchronization imposed by ventricular pacing may compromise ventricular function. We investigated whether heart rhythm regularization achieved through ventricular overdrive pacing (VP) gives additional benefit over rate control alone in patients with AF. METHODS: We studied 27 patients (mean age 72 +/- 7 years) with AF and normal left ventricular (LV) systolic function who were implanted with a common VVIR pacemaker. Cardiac function was assessed by using serial echocardiographic conventional, tissue Doppler imaging (TDI) and color M-Mode (CMM) examinations, together with B-type natriuretic peptide (BNP) measurements. Baseline data were obtained during AF (mean heart rate 58 +/- 5 beats/minute) with the pacemakers programmed to ventricular mere back-up pacing. These data were compared to the corresponding measurements following a 2-week VP period after the devises had been programmed to a lower rate of 70 beats/min, ensuring most of the time continuing VP. RESULTS: Continuous VP compared to AF, reduced the LV cardiac index (2.28 +/- 0.44 l/min/m(2) vs 2.33 +/- 0.39 l/min/m(2), P < 0.05), increased the LV end-systolic volume (38 +/- 14 mL vs 35 +/- 11 mL, P < 0.05), and decreased the TDI-derived systolic and diastolic mitral velocity (8.1 +/- 1.8 cm/s vs 8.3 +/- 1.6 cm/s, and 8.1 +/- 1.8 cm/s vs 8.3 +/- 1.6 cm/s, respectively, both P < 0.05) and the CMM-derived transmitral early diastolic flow propagation velocity (37.6 +/- 9.2 vs 41.5 +/- 9.7, P < 0.05). Following VP, both ratios E/Ea and E/Vp showed a trend toward increase (P = NS), whereas BNP rose up to 25.5% (median value, from 111 pg/mL to 165 pg/mL, P < 0.01). CONCLUSION: VP may be considered disadvantageous compared to slower AF.

The role of echocardiography and CT angiography in transcatheter aortic valve implantation patients.

The transcatheter aortic valve implantation (TAVI) consist an alternative treatment in patients with severe aortic stenosis. Multimodality imaging using transthoracic echocardiography (TTE) or transesophageal echocardiography (TOE) and multislice CT (MSCT) constitute cornerstone techniques for the pre-operative management, peri-procedural guidance, follow up and recognition of possible transcatheter valve related complications. CT angiography is much more accurate regarding the total definition of aortic annulus diameter and circumferential area. Two-dimensional (2D) echocardiography, underestimates the aortic valve annulus diameter compared to 3D imaging techniques (MSCT, MRI and 3D TOE). Three-dimensional TOE imaging provides measurements of the aortic valve annulus similar to those delivered by MSCT. The pre-procedural MSCT constitutes the gold standard modality minimizing the presence of paravalvular aortic regurgitation, one of the most frequent complications. TOE/TTE and MSCT performance could predict the possibility of pacemaker implantation post-procedural. The presence of a new transient or persisting MR can be assessed well by TOE. Both TTE and TOE, consist initially the basic examination for post TAVI evaluation. In case of transcatheter heart valve failure, the MSCT could be used as additional imaging technique.

Randomised comparison of JUDkins vs. tiGEr catheter in coronary angiography via the right radial artery: the JUDGE study.

AIMS: The aim of this study was to compare the performance of the Tiger-II with Judkins 3.5L/4R catheters in coronary angiography (CAG) via the transradial approach (TRA). METHODS AND RESULTS: Consecutive patients undergoing non-urgent CAG via the right TRA were randomised to either the Tiger-II (Terumo) or Judkins (3.5L/4R; Medtronic) 5 Fr catheters; 320 patients in each group were randomised. Catheter or access site change was required in 57 (17.8%) vs. 68 (21.3%) patients allocated to the Tiger-II and Judkins group, respectively (p=0.3). The study's primary endpoint of contrast volume (ml) used until completion of CAG was lower for Tiger-II vs. Judkins group: 66.8 (54.0-82.0) vs. 73.4 (60.0-94.1), p<0.001. Angiography, fluoroscopy time (min) and severe spasm rate were also significantly lower for Tiger-II vs. Judkins group: 5.52 (4.17-7.32) vs. 6.85 (5.15-9.63), p<0.00, 2.01 (1.32-3.13) vs. 2.24 (1.50-3.50), p=0.01 and 6 (2.8%) vs. 39 (12.2%), p<0.001, respectively. The Tiger-II catheter obtained better opacification grade for the right coronary artery (RCA): 4.0 (4.0-4.0) vs. 4.0 (3.0-4.0), p=0.02, but slightly compromised opacification of the left anterior descending (LAD) and left circumflex (LCX) arteries compared with the Judkins group: 3.75 (3.0-4.0) vs. 4.0 (3.5-4.0), p<0.001, and 3.78 (3.6-4.0) vs. 4.0 (3.6-4.0), p<0.001, respectively. CONCLUSIONS: The Tiger-II was found superior to the Judkins 3.5L/4R regarding contrast volume use, procedural and fluoroscopy time, spasm rate and RCA imaging, and inferior regarding LAD and LCX imaging.