Impact of short term oral steroid use for intravenous contrast media hypersensitivity prophylaxis in diabetic patients undergoing nonemergent coronary angiography or interventions.

OBJECTIVES: Oral steroids are routinely administered in the United States for prophylaxis of iodinated contrast media hypersensitivity (ICMH). We studied the impact of short-term steroid use in diabetic patients with ICMH undergoing nonemergent coronary angiography. METHODS: We retrospectively analyzed records of diabetic patients with and without ICMH who underwent nonemergent coronary angiography at our center. Primary study endpoint was 30-day major adverse cardiac events (MACE) and secondary endpoints were pre- and postprocedure fasting blood glucose (FBG), highest in hospital blood glucose, pre- and postprocedure systolic blood pressure (SBP), and use of intravenous insulin and antihypertensive medications. RESULTS: A total of 88 diabetics with ICMH (study group) and 76 diabetics without ICMH (control group) undergoing angiography were enrolled. Demographics and hemoglobin A1c values were similar in both groups. Preprocedural FBG was significantly higher in the study group. The study group had significantly higher post angiography FBG (239.93 + 96.88 mg/dl vs. 156.6 + 59.88 mg/dl) and greater use of intravenous (IV) insulin (67.27% vs. 32.43%). Further, those who received steroids had significantly higher systolic SBP postprocedure (146.16 + 25.35 mmHg vs. 130.8 + 21.59 mmHg), a higher incidence of severe hypertension and use of IV antihypertensive medications (80.95% vs. 19.05%) periprocedurally. There were no differences in 30-day MACE between groups. CONCLUSION: Short-term steroid use for ICMH results in a significant increase in surrogate markers for adverse clinical events after coronary procedures. Study findings highlight the need for better periprocedural management of these patients and to limit steroid prophylaxis to those with only true ICMH.

New generation drug-eluting stents for ST-elevation myocardial infarction: a new paradigm for safety.

OBJECTIVES: The objective of this study is to compare the long-term safety of new generation drug-eluting stents (DES) with early generation DES and bare metal stents (BMS) for ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Early generation DES for STEMI have reduced target vessel revascularization, but have more very late ST compared with BMS raising concerns about their safety. New compared with early generation DES have lower rates of ST, but there are limited data in STEMI patients. METHODS: From 2003 to 2011, 3,464 STEMI patients were treated with BMS (n = 1,187), early generation DES (n = 1,525), or new generation DES (n = 752) and were followed for 1-9 years. RESULTS: Patients with new generation DES were younger, had less cardiogenic shock, and less prior infarction versus BMS, and more hypertension versus early generation DES. At 2 years, new generation DES had lower mortality (4.0% vs. 12.4%, P < 0.001), similar reinfarction (4.4% vs. 5.1%, P = 0.35), and less ST (1.4% vs. 3.8%, P = 0.031) versus BMS; and similar mortality (4.0% vs. 5.8%, P = 0.23), similar reinfarction (4.4% vs. 5.2%, P = 0.64), and trends for less ST (1.4% vs. 3.3%, P = 0.17) versus early generation DES. By Cox multivariable analyses, BMS had more ST than new generation DES (HR [95% CI] = 1.93 [1.01-3.66], P = 0.045). CONCLUSIONS: New generation DES in STEMI patients have less ST compared to BMS and trends for less ST compared to early generation DES. These data suggest a new safety paradigm and should encourage the use of new generation DES in most STEMI patients treated with primary percutaneous coronary intervention (PCI).

Are adverse events following an invasive strategy in patients with non-ST-segment elevation acute coronary syndromes more frequent at US sites versus non-US sites? Analysis from the ACUITY trial.

OBJECTIVE: To compare outcomes between US and non-US (OUS) sites in patients with non ST-elevation acute coronary syndromes (NSTEACS) and to evaluate potential reasons for differences in outcomes. BACKGROUND: There are little data comparing outcomes at US versus OUS sites in patients with NSTEACS managed with an invasive strategy. METHODS: The ACUITY trial randomized 13,819 patients with NSTEACS in 17 countries to an invasive approach with one of three strategies: (1) heparin plus glycoprotein platelet inhibitors (GPI), (2) bivalirudin plus GPI, or (3) bivalirudin alone. RESULTS: US patients were more often female, were younger, heavier, and had more diabetes, prior myocardial infarction (MI), and prior bypass surgery. US patients were less often treated with percutaneous coronary intervention but had more frequent drug-eluting stent use. US patients had lower mortality and higher MI rates at 30 days and 1 year and higher composite ischemic outcome at 30 days. After adjusting for differences in baseline variables, US patients had higher rates of MI and composite ischemic outcome at 30 days and higher rates of MI at 1 year {HR [95% confidence interval (CI)] = 1.36 [1.18-1.56], P < 0.0001} with no differences in mortality. There were no differences in treatment effects comparing bivalirudin with the other strategies between US and OUS sites. CONCLUSIONS: US versus OUS patients with NSTEACS had higher adjusted rates of MI and ischemia. The reasons for these differences are not clear but may be due to unmeasured confounders, different thresholds for event reporting, or valid differences in systems of care which may impact outcomes.

From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery.

Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.

Persistent left superior vena cava draining into the left atrium.

A 40-year-old man was admitted with necrotising fasciitis of the right thigh. Further workup to evaluate for an infectious source revealed an incidental finding of persistent left superior vena cava via transesophageal echocardiography. This finding was confirmed by cardiac MRI. During his hospitalisation, he also developed altered mental status which was found to be secondary to systemic emboli by a head MRI. The primary source of infection was likely his dental abscesses. He underwent intravenous antibiotic therapy for a total of 6 weeks and was then referred to a specialised vascular centre for further management of his congenital anomaly.

Endoscopic radial artery harvesting for coronary artery bypass grafting. A single center evolving experience.

AIM: We sought to evaluate our experience with endoscopic radial artery harvesting for coronary artery bypass grafting (CABG). METHODS: From October 2005 to June 2010, 50 patients who underwent endoscopic radial artery harvesting for an elective CABG were prospectively assessed for harvesting characteristics, complications, postoperative and mid-term outcomes. RESULTS: There were 34 (68%) males and 16 (32%) females, average age 60.8 ± 9.2 years. All but two RA grafts (96%) were successfully harvested endoscopically. Mean harvesting time was 46.2 ± 9.3 min and mean length of harvested grafts was 23.4 ± 2.2 cm. In the post-operative period there were no wound-healing complications; residual forearm edema was recorded in 6 patients (12%) and peripheral neuropathy in 4 patients (8%). At 3 months after the surgery, peripheral neuropathy and residual edema persisted in 2 patients (4%). A significant drop of overall harvesting time (56.2 ± 18.6 vs. 38.6 ± 8.6 min, P<0.05) and forearm ischemia time (41.8 ± 12.7 vs. 24.2 ± 3.2 min, P<0.01) was found between first and last ten cases in the group. CONCLUSION: Endoscopic radial artery harvesting was associated with low risk of post-harvesting complications and most of these disappeared within a 3 months follow-up. However, there was a significant learning curve.

Adverse event rates following primary PCI for STEMI at US and non-US hospitals: three-year analysis from the HORIZONS-AMI trial.

AIMS: To examine outcomes in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) at US sites versus sites outside the US (OUS). METHODS AND RESULTS: In the HORIZONS-AMI trial 3,602 STEMI patients in 11 countries were randomised to primary PCI with bivalirudin versus heparin + glycoprotein IIb/IIIa inhibitors. US patients (n=814) had more diabetes, prior infarction, prior bypass surgery, and renal insufficiency. OUS patients (n=2,788) had longer door-to-balloon times, more radial access, fewer bypass surgeries, and were discharged more often on beta-blockers and statins. At three years US patients had higher mortality (9.7% vs. 6.0%, p=0.0003), reinfarction (10.2% vs. 6.4%, p=0.001), major adverse cardiac events (MACE; 28.2% vs. 20.1%, p<0.0001), major bleeding (16.9% vs. 6.4%, p<0.0001) and net adverse clinical events (NACE; 36.6% vs. 23.8%, p<0.0001), which persisted after adjusting for baseline risk. CONCLUSIONS: In the HORIZONS-AMI trial, STEMI patients undergoing primary PCI at US versus OUS sites had higher rates of adverse events, which persisted after adjusting for baseline risk. The reasons for these differences are not clear but may be due to unmeasured confounders, different thresholds for event reporting, or valid differences in systems of care and treatments.

Acute onset of generalised pruritus as presenting symptom of Klatskin tumour.

A 60-year-old Korean woman presented with generalised pruritus and abdominal pain. She was initially treated with oral antihistamine therapy, but upon progression of symptoms and jaundice involvement, she was found to have a Klatskin tumour. The patient was not a candidate for surgical resection and is currently undergoing palliative care.

Ventricular fibrillation coinciding with phentermine initiation.

A 70-year-old woman developed ventricular fibrillation subsequent to initiation of phentermine therapy. She was hospitalised and experienced recurrent ventricular fibrillation. During cardiac catheterisation, she was found to have a right coronary artery vasospasm, which resolved with intravenous nitroglycerin. Her phentermine was discontinued and the patient remained symptom free at last follow-up.