Use of Amplatzer occluders for treatment of aorto-pulmonary fistulas - case and review of the literature.

INTRODUCTION: the use of amplatzer occluder family in daily clinical practice has already overcome on-label indications, with growing clinical experience and the technological evolution of devices. Areas covered: We present the case of a patient with a very rare complication following proximal aortic surgery treated using a unique strategy. A huge pseudoaneurysm around an ascending aortic prosthesis ruptured into the right pulmonary artery. A hybrid treatment strategy consisting of percutaneous closure of the fistula followed by cardiosurgery was chosen due to the patient's poor haemodynamic condition. We also review current clinical experience of endovascular treatment of aortopulmonary fistulas by searching case reports in PubMed. Expert commentary: Closure of the APF using an Amplatzer occluder via the antegrade venous approach is feasible, and may improve the haemodynamic conditions and decrease the risk of subsequent cardiac surgery.

Clinical and laboratory predictors of Infectious Complications in patients after Out-of-Hospital Cardiac Arrest.

PURPOSE: Identification of clinical and laboratory predictors related to Infectious Complications (ICs) in patients after Out-of-Hospital Cardiac Arrest (OHCA). METHODS: Patients, aged >18, after an OHCA between 9/2013 and 11/2015, surviving >24h, were studied. RESULTS: Study group consisted of 42 patients (mean age 63.4years, 88.1% men). Forty percent of patients had IC; lower respiratory tract infections were most common (87.5% of cases). ICs were more common in patients receiving Targeted Temperature Management (50% vs. 10%; p=0.032). Antibiotics were used in 85.7% of patients. The mean time to therapy initiation was 9.6 (SD 7.1) hours after admission. The mean course of treatment was 9.0 (SD 6.2) days. Fifty-three percent of patients receiving early antibiotic treatment didn't have IC. Initial antibiotic therapy was changed more often in patients with IC (75% vs. 38.9%; p=0.045). C-Reactive Protein, Procalcitonin, Troponin and White Blood Cell count values were higher in patients with IC. CONCLUSION: Early initiated antibiotic treatment is overused in patients after OHCA. This practice is associated with necessitating antibiotic change in the majority of patients with IC. Assessment of clinical and laboratory parameters in the first days after OHCA increases the likelihood of appropriate ATB therapy.

Characteristics and Survival Determinants in Patients After Out-of-Hospital Cardiac Arrest in The Era of 24/7 Coronary Intervention Facilities.

BACKGROUND: Survival rates and outcomes after out-of-hospital cardiac arrest (OHCA) remain low despite investments of time and money. The goal of this analysis was to identify variables related to survival of patients transferred to our coronary care unit (CCU) after an OHCA. METHODS: 102 consecutive OHCA patients, mean age 64.6 (SD 13.3), 70.6% men, between January, 2011 and December, 2013, who were transferred to our tertiary care CCU, were studied. RESULTS: Cardiac-cause OHCA was present in 84 patients (82.4%). Of these 60.7% had an acute coronary syndrome (ACS) - STEMI 35.7%; NSTEMI 23.8%. Coronary angiography was performed in 73 (71.6%) patients - 81% with cardiac- and 31.3% (5/16) with a non-cardiac cause. Percutaneous coronary intervention (PCI) was performed in 50 patients (68.5%), 49 with cardiac-cause, and succeeded in 92%. In-hospital mortality was 38.2%, one-year mortality was 51.5%. In-hospital and one-year mortality were related to age (p=0.002 resp. p=0.001), first ECG rhythm (p=0.001, resp. p=0.005), history of coronary artery disease (RR 2.1; p=0.026 resp. RR 1.71; p=0.029), and history of arrhythmia (supraventricular tachyarrhythmia, bradyarrhythmia) (RR 2.74; p=0.003 resp. RR 2.3; p=0.001). One-year mortality was also related to a history of diabetes mellitus (RR 1.89; p=0.006). CONCLUSION: Cardiac-cause was the most common cause of OHCA. Acute coronary syndrome was present in more than half of the cases. Availability of interventional facilities was a crucial factor in OHCA management. A history of coronary artery disease, diabetes mellitus, and arrhythmia were associated with worse survival.

The impact of stage of chronic kidney disease on the outcomes of diabetics with acute myocardial infarction treated with percutaneous coronary intervention.

BACKGROUND: Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) have a high risk of acute myocardial infarction and recurrent cardiovascular events. According to the previous studies, the combination of the two conditions may have a synergistic impact on prognosis. The aim of this study was to assess the impact of stage of CKD on the outcomes of patients with DM and ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). METHODS: Study population consisted of 946 consecutive patients with STEMI who underwent PCI from January 2009 to December 2012 and were followed up until the end of 2013. The all-cause mortality during this period was evaluated in relation to DM and severe or moderate reduction in glomerular filtration rate (GFR categories G4-5, or G3; KDIGO classification). Cox regression analysis adjusted for possible confounding factors was used in statistics. RESULTS: Out of the study population (mean age 63 years, 69.6 % males), 217 (22.9 %) patients had DM. Of them, 10.6 % were in GFR category G4-5 and 32.7 % in G3. The in-hospital mortality rates in patients with DM were 34.8 % for G4-5, 18.3 % for G3, and 4.1 % in G1-2 groups. The all-cause mortality at the end of the follow-up period for diabetics within G4-5 was 2.27 -times higher compared to mortality of diabetics in G1-2 (p = 0.047, Cox regression analysis), and there was a trend toward higher mortality for G3 versus G1-2 (HR 1.64, p = 0.12). CONCLUSION: Severe chronic kidney disease (GFR category 4-5) was significantly associated with all-cause mortality of diabetics with STEMI treated with PCI; the association with severe CKD was stronger compared to moderate CKD.

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion.

BACKGROUND: Percutaneous coronary intervention (PCI) performed within 12 h from symptom onset enables complete blood flow restoration in infarct-related artery in 90% of patients. Nevertheless, even with complete restoration of epicardial blood flow in culprit vessel (postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3), myocardial perfusion at tissue level may be insufficient. We hypothesized that the outcome of patients with STEMI/bundle branch block (BBB)-myocardial infarction and post-PCI TIMI 3 flow is related to the time to reperfusion. METHODS: Observational study based on a retrospective analysis of population of 635 consecutive patients with STEMI/BBB-MI and post-PCI TIMI 3 flow from January 2009 to December 2011 (mean age 63 years, 69.6% males). Mortality of patients was evaluated in relation to the time from symptom onset to reperfusion. RESULTS: A total of 83 patients (13.07%) with postprocedural TIMI 3 flow after PCI had died at 1-year follow-up. Median TD in patients who survived was 3.92 h (iqr 5.43), in patients who died 6.0 h (iqr 11.42), P = 0.004. Multiple logistic regression analysis identified time delay ≥ 9 h as significantly related to 1-year mortality of patients with STEMI/BBB-MI and post-PCI TIMI 3 flow (OR 1.958, P = 0.026). Other significant variables associated with mortality in multivariate regression analysis were: left ventricle ejection fraction < 30% (P = 0.006), age > 65 years (P < 0.001), Killip class >2 (P <0.001), female gender (P = 0.019), and creatinine clearance < 30 mL/min (P < 0.001). CONCLUSION: Time delay to reperfusion is significantly related to 1-year mortality of patients with STEMI/BBB-MI and complete restoration of epicardial blood flow in culprit vessel after PCI.

Selection of P2Y12 antagonist, treatment initiation, and predictors of high on-treatment platelet reactivity in a "Real World" registry.

OBJECTIVE: The present study aimed to compare characteristics related to selection of a P2Y12 antagonist, investigate initiation of therapy with new-generation drugs, and identify predictors of high on-treatment platelet reactivity (HTPR) in patients with acute coronary syndrome treated with stent percutaneous coronary intervention (PCI). METHODS AND RESULTS: Data from 589 patients in the LAPCOR (Laboratory AntiPlatelet efficacy and Clinical Outcome Registry; ClinicalTrials.gov Identifier: NCT02264912) registry was analyzed. P2Y12 receptor antagonist efficacy was measured by VASP phosphorylation 24 ± 4 hours after a loading dose of clopidogrel (600 mg, N=407), prasugrel (60 mg, N=106), or ticagrelor (180 mg, N=76) and expressed by platelet reactivity index (PRI). HTPR was defined as PRI ≥50%. Patients treated with prasugrel were significantly younger and had significantly higher hemoglobin levels than those who received clopidogrel or ticagrelor, while chronic kidney disease was significantly more prevalent in the ticagrelor group. Almost all invasively managed patients given new-generation drugs received a loading dose after coronary angiography. Mean residual PRI and HTPR were significantly higher after clopidogrel (44.2 ± 23.1% and 42.2%, respectively) vs. prasugrel (17.7 ± 18.0% and 9.4%, respectively) or ticagrelor (18.8 ± 17.0% and 7.9%, respectively; all p<0.001). Among multiple variables tested, HTPR in patients treated with the new agents significantly related only to platelet count (p=0.014) and mean platelet volume (p=0.03). CONCLUSION: Safety is the most important aspect under consideration in choosing new agents for an individual patient. Other than platelet count and mean platelet volume, factors known as predictors of higher platelet reactivity, did not influence the efficacy of new-generation P2Y12 receptor antagonists.

Two sporadic infected cardiac myxomas in 1 patient.

Infected cardiac myxoma is a rare cause of endocarditis. The finding of coexisting infected cardiac myxomas is highly unusual. Herein, we present the case of a 58-year-old woman with a low-grade fever. Laboratory findings strongly indicated inflammation, and blood cultures detected Staphylococcus species. Echocardiograms revealed mobile masses in the area of the mitral valve. Transesophageal echocardiograms showed 2 formations that arose from opposite sides of the mitral annulus and protruded into the left ventricle during systole. During emergency surgery, 2 abnormal growths with numerous vegetations were completely excised. The diagnosis of myxoma was confirmed upon histologic evaluation. Microbiological and polymerase chain reaction analysis of the myxomas detected the bacterial strain Enterococcus faecalis. Five months postoperatively, the patient showed no signs of recurrent infection and had a normal echocardiographic appearance.This report is the first of an infected cardiac myxoma in the Czech population and one of approximately 60 reports in the medical literature from 1956 to the present. In addition to the case of our patient, we discuss the discrepancy between the bacteriologic findings.