Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention.

The aim of this study was to define the incidence of left ventricular thrombus (LVT) and its predictors in the contemporary era of primary percutaneous intervention (pPCI) and contrast echocardiography. We retrospectively analyzed 1,059 patients presenting with ST-elevation myocardial infarction (STEMI) to our tertiary cardiac center and treated with pPCI. Preprocedural pharmacology and procedural technique (including access route, the use of drug-eluting stents, and thrombectomy) were at the operators' discretion. Transthoracic echocardiography was performed before discharge; echo contrast agent was used when appropriate. LVT was detected in 42 subjects (4%). There were no significant differences in baseline demographics or pre-PCI clinical features between the 2 groups. Post-treatment, mean ejection fraction (EF) in patients with LVT was 35±8.4% and in those without LVT was 47±10%, p<0.001. Thirty-seven patients (88%) in the LVT group presented with an anterior STEMI versus 471 patients (42%) in the without LVT group (p<0.001). Apical akinesis was noted in all patients with LVT irrespective of the principal location of the MI. Multivariate analysis predictors of LVT were reduced EF, anterior site of MI, and the use of platelet glycoprotein IIb/IIIa inhibitors. After diagnosis of LVT, patients were treated with warfarin for 3 to 6 months. No significant difference in mortality was detectable at discharge between the 2 groups. In conclusion, in the contemporary era of pPCI, the incidence of LVT in patients with STEMI is significantly lower than that of the previous (thrombolysis) literature. The early presence of LVT is more likely in patients with anterior STEMI (involving the apex) and reduced EF.

Real-time three-dimensional transesophageal echocardiography adds value to transcatheter aortic valve implantation.

BACKGROUND: Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. METHODS: TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. RESULTS: Procedural success was achieved in 99% of 256 patients (mean age, 82.9 ± 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 ± 11.2%; mean aortic valve area, 0.63 ± 0.19 cm(2)), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 ± 1.9 mm, 22.5 ± 2.2 mm (P < .001), and 23.0 ± 2.0 mm (P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. CONCLUSIONS: A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

Acute beta-adrenoceptor blockade improves efficacy of ibutilide in conversion of atrial fibrillation with a rapid ventricular rate.

AIMS: Activation of beta-adrenoceptors attenuates prolongation of action potential duration induced by blockade of the delayed rectifier potassium current. We examined whether acute administration of beta-blocker could enhance ibutilide (IB) efficacy in conversion of atrial fibrillation (AF) with a rapid ventricular rate. METHODS AND RESULTS: Ninety patients (aged 63 +/- 13.5 years) with rapidly conducting AF were randomized in to two groups. Group A (n = 44) received esmolol titrated to achieve a heart rate of <100 bpm followed by IB co-administration, while Group B (n = 46) were treated with IB as monotherapy. In Group A, 29 patients (67%) converted to sinus rhythm (SR) compared with 21 (46%) in Group B (P = 0.04). The use of esmolol was the most important predictor for cardioversion (P = 0.009). The slower the heart rate at the time of IB initiation, the higher the likelihood for cardioversion (P = 0.015). Patients in Group A had significantly shorter corrected QT interval (QTc) at the time of conversion than those in Group B (433 vs. 501 ms, P = 0.003). Two patients in Group A developed severe bradycardia, whereas three patients in Group B developed severe ventricular tachycardia (VT). CONCLUSION: Compared with IB monotherapy, the combination therapy of esmolol and IB appears to be more effective in conversion of rapidly conducting AF back to SR. The addition of beta-blocker reduces QTc prolongation and diminishes the risk of VT at the expense, however, of increased bradycardic events.

Low dose sodium valproate in the treatment of juvenile myoclonic epilepsy.

Fourteen patients with juvenile myoclonic epilepsy (JME) were treated with a single low dose of a sustained-release preparation of sodium valproate (VPA, 500 mg daily). The mean age of the onset of the low dose treatment was 19.2 years (range 14-26). Before this treatment, six patients had been treated with high dose VPA for a period of more than 2 years, three patients for 1 to 2 years, three patients less than 1 year and two patients initiated the treatment from the beginning with a low dose. The mean duration of low dose treatment is 35.6 months (range 25-59 months). (All patients are still under medication). Generalized tonic-clonic and absence seizures were controlled in all patients. Myoclonic jerks relapsed only in one patient, a young mother who was looking after her newly born baby and was deprived of sleep. No adverse reactions have been reported. We suggest that JME patients can effectively be treated with single low VPA dose (500 mg daily), while at the same time seizure precipitating factors, such as sleep deprivation and alcohol ingestion, should be avoided.