Myocardial work in patients with heart failure and ischemic cardiomyopathy according to the mode of coronary revascularization.

BACKGROUND: The association of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on myocardial function, as reflected in myocardial work (MyW) parameters, in patients with ischemic cardiomyopathy and heart failure (HF) is unknown. METHODS: We analyzed data from 68 patients who were hospitalized with chronic HF due to ischemic cardiomyopathy and stratified them according to the mode of revascularization. All patients underwent a 2D speckle tracking echocardiography exam performed by the same expert sonographer and had complete MyW data including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). RESULTS: The mean age of patients was 70 ± 10 years and 86.8% were men. The mean left ventricular ejection fraction (LVEF) in overall cohort was 31.6 ± 9.5%. Both subgroups did not significantly differ in terms of baseline LVEF, comorbidities, and pharmacotherapy. Compared with those who received PCI, patients revascularized with CABG had significantly greater GWI (821 vs. 555 mmHg%, p = 0.002), GCW (1101 vs. 794 mmHg%, p = 0.001), GWE (78 vs. 72.6%, p = 0.025), and global longitudinal strain (-8.7 vs. -6.7%, p = 0.004). Both patient subgroups did not significantly differ with respect to GWW (273 vs. 245 mmHg%, p = 0.410 for CABG and PCI, respectively) and survival during the median follow-up of 18 months (log-rank p = 0.813). CONCLUSION: Patients with HF and ischemic cardiomyopathy revascularized with CABG had greater myocardial work performance when compared with those revascularized with PCI. This might suggest a higher degree of functional myocardial revascularization associated with the CABG procedure.

Emerging Therapies for the Treatment of Atherosclerotic Cardiovascular Disease: From Bench to Bedside.

Primarily a consequence of sedentary lifestyle, atherosclerosis has already reached pandemic proportions, and with every year the burden of it is only increasing. As low-density lipoprotein cholesterol (LDL-C) represents a crucial factor in atherosclerosis formation and progression, stringent lipid-lowering therapy could conceivably be the key to preventing the unfavorable outcomes that arise as a consequence of atherosclerosis. The use of statins in lipid-lowering is often burdened by adverse events or is insufficient to prevent cardiovascular events as a monotherapy. Therefore, in the present review, the authors aimed to discuss the underlying mechanisms of dyslipidemia and associated atherosclerotic cardiovascular disease (ASCVD) and preclinical and clinical trials of novel therapeutic approaches to its treatment, some of which are still in the early stages of development. Apart from novel therapies, a novel change in perspective is needed. Specifically, the critical objective in the future management of ASCVD is to embrace emerging evidence in the field of atherosclerosis, because clinicians are often burden by common practice and personal experience, both of which have so far been shown to be futile in the setting of atherosclerosis.

Conservative Management of Spontaneous Left Main Coronary Artery Dissection (SCAD) Triggered by Emotional Stress in the Late Postpartum Period: Case Report and Pathophysiology.

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.

Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.

INTRODUCTION: Proximal venous approaches (femoral or jugular) for catheter-directed thrombolysis (CDT) of acute pulmonary embolism (PE) dominate in clinical practice. AIM: We investigated the feasibility and safety of CDT in acute PE by using the superficial cubital venous approach. MATERIAL AND METHODS: All patients with acute PE received intravenous unfractionated heparin plus CDT. CDT included mechanical thrombus fragmentation and the local application of adjuvant thrombolytic therapy through the pigtail catheter - alteplase administered as 2.5 mg bolus in each main branch of the pulmonary artery plus adjuvant 25 mg for 12 h in the more severely affected branch of the pulmonary artery. RESULTS: Twenty-seven consecutive patients presenting with acute massive (high risk) PE (n = 10) or submassive (intermediate risk) PE (n = 17) were enrolled in the study. The mean age of the enrolled cohort was 60.6 (14.1) years and most patients were female (n = 14, 52%). The procedural success of CDT application through the cubital vein was achieved in all patients. After the procedure, the systolic pulmonary artery pressure decreased from 61.4 (18.3) to 35.8 (12.3) mm Hg (p < 0.001) while the mean pulmonary artery pressure decreased from 35.7 (10.8) to 21.1 (6.5) mm Hg (p < 0.001). Similarly, the mean arterial pressure increased from 81.9 (12.8) to 89.0 (10.3) mm Hg (p = 0.031). Miller angiographic obstruction score and Miller index decreased significantly after the CDT intervention (p < 0.001). There were no deaths, major bleeding events, or hemorrhagic strokes. CONCLUSIONS: CDT by using the cubital approach is a simple, safe, and feasible treatment option for PE. This approach was associated with significant improvement in hemodynamic parameters without fatal outcomes or major periprocedural complications.

In-hospital mortality of patients with acute myocardial infarction before and after introduction of PCI in Split University Hospital Center, Croatia.

Aim of the study was to estimate the in-hospital mortality and death rate in patients with AMI according to gender and location of infarction during 5 years before and after the introduction of percutaneous coronary intervention (PCI) procedures in Split University Hosptial Center, Croatia. The hospitalized patients were divided in two groups, from 2000 to 2004 and from 2005 to 2009. The analysis included total mortality and mortality according to gender and location of AMI. The location of infarction was detected toward typical ECG changes. The analysis included the model of death in patients with AMI and in-hospital mortality of patients undergoing the PCI procedures. The patients in the first group were treated with the standard medication therapy, and the patients in the second group were treated with PCI. The number of hospitalized patients with AMI, in ten years, increased from 475 to 652. A total of 5339 patients with AMI were hospitalized, and included 67.5% males and 32.5% females. The first group included 2336 patients (68% males and 32% females). The second group included 2973 patients (67% males and 33% females). Male patients in average were 5 years younger than female patients. A total in-hospital mortality was significantly higher in the first group (13.5 vs. 7.6%). The mortality in the first group was significantly higher in females (22.7 vs. 12%) and in males (9 vs. 5.5%) comparing with second group. In-hospital mortality in the patients with STEMI was significantly higher in the first group (16.6 vs. 9%). Among the patients with NSTEMI there were no significantly differences in the in-hospital mortality (4 vs. 2.5%). The most frequent trigger of death in males were ventricular fibrillation in both groups such as heart failure in females. Cx occlusion is more often among the male patients treated with PCI. In-hospital mortality in patients with STEMI treated with PCI was 5.7%. A in-hospital mortality in the patients with AIM after PCI was almost halved. Females had two times higher in-hospital mortality before and after PCI introduction.

Effect of repetitive SCUBA diving on humoral markers of endothelial and central nervous system integrity.

During SCUBA diving decompression, there is a significant gas bubble production in systemic veins, with rather frequent bubble crossover to arterial side even in asymptomatic divers. The aim of the current study was to investigate potential changes in humoral markers of endothelial and brain damage (endothelin-1, neuron-specific enolase and S-100ß) after repetitive SCUBA diving with concomitant assessment of venous gas bubble production and subsequent arterialization. Sixteen male divers performed four open-water no-decompression dives to 18 msw (meters of sea water) lasting 49 min in consecutive days during which they performed moderate-level exercise. Before and after dives 1 and 4 blood was drawn, and bubble production and potential arterialization were echocardiographically evaluated. In addition, a control dive to 5 msw was performed with same duration, water temperature and exercise load. SCUBA diving to 18 msw caused significant bubble production with arterializations in six divers after dive 1 and in four divers after dive 4. Blood levels of endothelin-1 and neuron-specific enolase did not change after diving, but levels of S-100ß were significantly elevated after both dives to 18 msw and a control dive. Creatine kinase activity following a control dive was also significantly increased. Although serum S-100ß levels were increased after diving, concomitant increase of creatine kinase during control, almost bubble-free, dive suggests the extracranial release of S-100ß, most likely from skeletal muscles. Therefore, despite the significant bubble production and sporadic arterialization after open-water dives to 18 msw, the current study found no signs of damage to neurons or the blood-brain barrier.

[Primary percutaneous coronary intervention (pPCI) in hospital without regional cardiac surgery support, data from Split region]. / Primarna perkutana koronarna intervencija (pPCI) bez kardiokirurske potpore u regiji; iskustvo iz Splita.

OBJECTIVES: The aim of our study was to investigate the feasibility of pPCI in hospital without cardiac surgery, and to compare our "real-world" results to current guidelines and historical controls. METHODS: Data of all STEMI patients treated by PCI were prospectively recorded. RESULTS: From January 2005 through October 2007, 366 consecutive patients with STEMI were enrolled. In-hospital mortality was 6.3%, as compared to 15% (87/543) in historical records of a three year period before pPCI program was developed. Pain to balloon time was 315 minutes, pain to first medical contact was 102 minutes, first medical contact to door was 94 minutes, door to cathlab time was 84 minutes, cathlab to balloon time was 45 minutes, and door to balloon time was 129 minutes. CONCLUSIONS: Our preliminary experience indicates that implementation of pPCI in a hospital without regional cardiac surgical back-up is feasible and offers significant mortality reduction in STEMI patients. Intrahospital time delays should be managed aggressively.

Determinants of arterial gas embolism after scuba diving.

Scuba diving is associated with breathing gas at increased pressure, which often leads to tissue gas supersaturation during ascent and the formation of venous gas emboli (VGE). VGE crossover to systemic arteries (arterialization), mostly through the patent foramen ovale, has been implicated in various diving-related pathologies. Since recent research has shown that arterializations frequently occur in the absence of cardiac septal defects, our aim was to investigate the mechanisms responsible for these events. Divers who tested negative for patent foramen ovale were subjected to laboratory testing where agitated saline contrast bubbles were injected in the cubital vein at rest and exercise. The individual propensity for transpulmonary bubble passage was evaluated echocardiographically. The same subjects performed a standard air dive followed by an echosonographic assessment of VGE generation (graded on a scale of 0-5) and distribution. Twenty-three of thirty-four subjects allowed the transpulmonary passage of saline contrast bubbles in the laboratory at rest or after a mild/moderate exercise, and nine of them arterialized after a field dive. All subjects with postdive arterialization had bubble loads reaching or exceeding grade 4B in the right heart. In individuals without transpulmonary passage of saline contrast bubbles, injected either at rest or after an exercise bout, no postdive arterialization was detected. Therefore, postdive VGE arterialization occurs in subjects that meet two criteria: 1) transpulmonary shunting of contrast bubbles at rest or at mild/moderate exercise and 2) VGE generation after a dive reaches the threshold grade. These findings may represent a novel concept in approach to diving, where diving routines will be tailored individually.

Cardiovascular changes during underwater static and dynamic breath-hold dives in trained divers.

Limited information exists concerning arterial blood pressure (BP) changes in underwater breath-hold diving. Simulated chamber dives to 50 m of freshwater (mfw) reported very high levels of invasive BP in two divers during static apnea (SA), whereas a recent study using a noninvasive subaquatic sphygmomanometer reported unchanged or mildly increased values at 10 m SA dive. In this study we investigated underwater BP changes during not only SA but, for the first time, dynamic apnea (DA) and shortened (SHT) DA in 16 trained breath-hold divers. Measurements included BP (subaquatic sphygmomanometer), ECG, and pulse oxymetry (arterial oxygen saturation, SpO2, and heart rate). BP was measured during dry conditions, at surface fully immersed (SA), and at 2 mfw (DA and SHT DA), whereas ECG and pulse oxymetry were measured continuously. We have found significantly higher mean arterial pressure (MAP) values in SA (∼40%) vs. SHT DA (∼30%). Postapneic recovery of BP was slightly slower after SHT DA. Significantly higher BP gain (mmHg/duration of apnea in s) was found in SHT DA vs. SA. Furthermore, DA attempts resulted in faster desaturation vs. SA. In conclusion, we have found moderate increases in BP during SA, DA, and SHT DA. These cardiovascular changes during immersed SA and DA are in agreement with those reported for dry SA and DA.

Gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

There are conflicting reports in the literature regarding the role of sex on the in-hospital mortality of patients with acute myocardial infarction. The objective of this study is to determine whether there are gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We conducted a prospective study of all patients admitted to University Hospital Center Split, Croatia with STEMI from 2004 to 2008 who underwent PCI. From March 2004 throughout September 2008, 488 patients with STEMI underwent PCI (364 men, 74.6%; 124 women, 25.4%). Compared with men, women were significantly older (mean age, 67.3 vs. 60.3 years; p < 0.001). Men had a significantly higher proportion of circumflex artery occlusion (19.5% vs. 10.5%, p = 0.022). A higher proportion of men had a multivessel disease than women (56.8% vs. 41.9%; p = 0.004). In-hospital mortality was significantly higher among women (11.3% vs. 4.6%; p = 0.002) but after adjustment for the baseline difference in age, the female sex was not an independent predictor of in-hospital mortality (adjusted OR 1.15; 95% CI 0.82-1.84). In men, occlusions of left anterior descending artery showed higher mortality rate than occlusions of other coronary arteries (LM 0%, LAD 7.3%, Cx 2.8%, RCA 0.7%, p = 0.03). According to our results female gender is not an independent predictor of in-hospital mortality after percutaneous coronary intervention. In men, occlusions of left anterior descending arteries are associated with higher mortality rate comparing to occlusions of other coronary arteries.

Glucose-6-phosphate dehydrogenase deficiency and idiopathic presenile cataract in Dalmatia, Croatia.

BACKGROUND: Impaired activity of the enzyme glucose-6-phosphate dehydrogenase (G6PD) has been suggested as a risk factor in cataractogenesis. The aim of this study was to determine the G6PD activity level in 89 male subjects of Dalmatian origin with idiopathic presenile cataracts. METHODS: G6PD activity was determined by a quantitative spectrophotometric method. RESULTS: Of 89 males with presenile cataracts only one (1.1%) had G6PD deficiency. The G6PD deficiency prevalence rate among males with presenile cataracts is not significantly different (p > 0.05) from the prevalence of G6PD deficiency in the general population of Dalmatia (0.75% among men). INTERPRETATION: The results of this study suggest that G6PD deficiency does not represent a pathogenetic factor in presenile cataract, at least not in the population of the southern part of Croatia.

Neurodevelopmental disabilities and quality of life after intensive care treatment.

AIM: To analyze the quality of life after Pediatric Intensive Care Unit (PICU) treatment and compare the differences between quality of life in children who suffer chronic health conditions, and those who do not, post discharge from PICU. METHOD: Quality of life was assessed using the Royal Alexandra Hospital for Children (RAHC) Measure of Function which incorporates measures of domains that delineate severity or impact of disease symptoms, physical disability, mobility, emotional distress, behavior, deviation from normal growth and development, impairment in social rules, and performance at school and in leisure activities. RESULTS: Families of 371 children were contacted for RAHC Measure of Function scoring. The results showed that the majority of children with no chronic condition (88.8%), as well as those with a chronic condition other than neurodevelopmental disability (81.6%) had minimal ongoing health problems and good quality of life. Only 21.4% of children with neurodevelopmental disabilities fell into this category, 39.3% had poor quality of life and 39.3% had fair quality of life. CONCLUSION: The results suggest that the majority of patients discharged from the PICU go on to have a good quality of life. The quality of life of patients with other chronic condition did not differ significantly from children who did not suffer from a chronic condition, with the majority of both groups having minimal residual health problems. Conversely, children with neurodevelopmental disabilities were found to have a higher level of health problems and only a fair quality of life compared with the other two groups.