Pectus excavatum requiring temporary pacemaker implantation before Nuss procedure: a case report.

Pectus excavatum is the most common chest wall deformity, and some patients also have it combined with cardiac arrhythmias. It is a rare occurrence for there to be a severe conduction block that requires a temporary pacemaker implantation before the surgical correction. Here we reported a case of pectus excavatum with a second-degree atrial-ventricular (AV) block (Mobitz II) who had temporary pacemaker implantation before the Nuss procedure. The young patient had a chest wall deformity for 6 years and it got worse with age. The Haller index was 4.21, and we evaluated that he should receive the Nuss procedure. An AV block was found during the preoperative electrocardiogram examination; furthermore, Holter monitor proved that he had first-degree AV block and a second-degree AV block (Mobitz II). After consultation with the anesthesiologist and cardiologist, we suggested that a temporary pacemaker placement should be performed under local anesthesia before the minimally invasive operation and removed as soon as the patient revived from general anesthesia. A postoperative Holter monitor was implemented, and the conduction defect disappeared shortly after the operation. However, the Holter monitor showed that the conduction defect was still existed during the follow-up period, which indicated that severe conduction defects should be originated from the conduction system itself, rather than the compression to the heart. The temporary pacemaker was essential to ensure the conducting of the operation went smoothly.

Effects of recombinant human brain natriuretic peptide on the prognosis of patients with acute anterior myocardial infarction undergoing primary percutaneous coronary intervention: a prospective, multi-center, randomized clinical trial.

BACKGROUND: This study aims to investigate the effects of recombinant human brain natriuretic peptide (rhBNP) on serum enzyme data, cardiac function parameters and cardiovascular events in patients with acute anterior myocardial infarction (MI). METHODS: A total of 421 patients with acute anterior or extensive anterior MI were collected from 20 hospitals. These patients were randomly divided into two groups: rhBNP and control groups. Both groups of patients received primary percutaneous coronary intervention (PCI) within the effective time window. In the rhBNP group, rhBNP administration (0.01 µg/kg/min, 48-72 successive hours) was performed as early as possible after hospital admission. Prior to and one or seven days after PCI, serum concentrations of cardiac troponin (cTnT), creatine kinase-MB (CK-MB) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured. At seven days and 6 months after PCI, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDd) and stroke volume (SV) were measured using 2D Doppler echocardiography. MACEs that occurred during hospitalization and within 6 months after PCI were recorded. RESULTS: At postoperative days one and seven, serum concentrations of cTnT were significantly lower in the rhBNP group than in the control group. At postoperative day one, serum concentrations of CK-MB were significantly lower in the rhBNP group than in the control group. At postoperative day seven, serum concentrations of NT-proBNP were significantly lower in the rhBNP group than in the control group, and LVEF was significantly greater in the rhBNP group than in the control group. At postoperative 6 months, LVEDd was significantly lower in the rhBNP group compared with the control group. In addition, SV and LVEF were significantly greater in the rhBNP group than in the control group. By postoperative month 6, the incidence of composite cardiovascular events (16.0% vs. 26.0%, P=0.012), cardiac death (7.0% vs.13.5%, P=0.030), and particularly cardiac death + re-hospitalization for congestive heart failure (13.1% vs. 25.5%, P=0.001) were significantly lower in the rhBNP group than in the control group. CONCLUSIONS: Early intravenous rhBNP administration after PCI significantly lowered the serum concentrations of cTnT and NT-proBNP, increased LVEDd, SV and LVEF, and reduced MACEs, including cardiac death, in patients with acute anterior MI undergoing PCI.

Safety and efficacy of policosanol in patients with high on-treatment platelet reactivity after drug-eluting stent implantation: two-year follow-up results.

OBJECTIVES: To investigate safety and efficacy of policosanol in patients with high on-treatment platelet reactivity after drug-eluting stent implantation. BACKGROUND: Certain number of patients has high residual platelet reactivity on clopidogrel after coronary intervention, and their risk of thrombotic events is high. METHOD: In this prospective, randomized trial conducted in four Chinese sites, 350 patients with high on-treatment platelet reactivity (HPR, defined as platelet aggregation >65%) were randomized by the ratio of 1:3:3 to: group A, clopidogrel 75 mg/d for 1 year (n=50); group B, clopidogrel 150 mg/d for 30 days followed by 75 mg/d until 1 year (n=150); or group C, policosanol 40 mg/d for 6 month and clopidogrel 75 mg/d for 1 year (n=150). All of them were treated with aspirin. The primary endpoint was the reversion rate of HPR at 1 month (reversion was defined as platelet aggregation <65%). The secondary endpoints were 6-month major adverse cardiac events (MACE), which included cardiac death, nonfatal myocardial infarction, or ischemic symptoms driven target vessel revascularization. RESULTS: At 30 days, the reversion rate of HPR was 34.0%, 55.2%, and 48.7% in group A, group B, and group C, respectively (P=.029). Major adverse cardiac events occurred in 4 (8.0%), 6(4.0%), and 5(3.3%) patients (P=.342). There was 1 (0.7%) major bleeding and 1 (0.7%) minor bleeding event in high maintenance dose clopidogrel group, no major or moderate bleeding in the other two groups. The minimal bleeding in group B was significantly higher than group C (10.7% vs 2.7%, P=.022). At 2-year follow-up, the benefits of policosanol on bleedings persisted compared with group B. CONCLUSIONS: Policosanol reduced platelet reactivity to a similar extent as high maintenance dose of clopidogrel without increasing bleeding rate.

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent: Randomized Substudy of the I-LOVE-IT 2 Trial.

BACKGROUND: There are no reports on a large-scale randomized trial exploring optimal dual antiplatelet therapy (DAPT) duration after biodegradable polymer sirolimus-eluting stent implantation. We sought to report the outcomes of a randomized substudy of the prospective Evaluate Safety and Effectiveness of the Tivoli DES and the Firebird DES for Treatment of Coronary Revascularization (I-LOVE-IT 2) trial. METHODS AND RESULTS: In the prospective noninferiority randomized I-LOVE-IT 2 trial, 1829 patients allocated to the biodegradable polymer sirolimus-eluting stent group were also randomized to receive either 6-month (n=909) or 12-month DAPT (n=920). The primary end points of this noninferiority substudy were 12-month target lesion failure (composite of cardiac death, target vessel myocardial infarction or clinically indicated target lesion revascularization), and the major secondary end points were 12-month net adverse clinical and cerebral events (composite of all-cause death, all myocardial infarction, stroke, or major bleeding [Bleeding Academic Research Consortium type ≥3]). The 12-month target lesion failure in 6-month DAPT group was comparable with the 12-month DAPT group (6.8% versus 5.9%; difference and 95% confidence interval, 0.87% [-1.37% to 3.11%], P for noninferiority=0.0065). Further follow-up at 18 months showed that incidence of target lesion failure and net adverse clinical and cerebral events were similar between the 2 groups (7.5% versus 6.3%, log-rank P=0.32; 7.8% versus 7.3%, log-rank P=0.60; respectively), as well as their individual end point components. CONCLUSIONS: This study indicated noninferiority in safety and efficacy of 6-month versus 12-month DAPT after implantation of a novel biodegradable polymer sirolimus-eluting stent. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01681381.

Bivalirudin vs heparin with or without tirofiban during primary percutaneous coronary intervention in acute myocardial infarction: the BRIGHT randomized clinical trial.

IMPORTANCE: The safety and efficacy of bivalirudin compared with heparin with or without glycoprotein IIb/IIIa inhibitors in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are uncertain. OBJECTIVE: To determine if bivalirudin is superior to heparin alone and to heparin plus tirofiban during primary PCI. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, open-label trial involving 2194 patients with AMI undergoing primary PCI at 82 centers in China between August 2012 and June 2013. INTERVENTIONS: Patients were randomly assigned to receive bivalirudin with a post-PCI infusion (n = 735), heparin alone (n = 729), or heparin plus tirofiban with a post-PCI infusion (n = 730). Among patients treated with bivalirudin, a postprocedure 1.75 mg/kg/h infusion was administered for a median of 180 minutes (IQR, 148-240 minutes). MAIN OUTCOMES AND MEASURES: The primary end point was 30-day net adverse clinical events, a composite of major adverse cardiac or cerebral events (all-cause death, reinfarction, ischemia-driven target vessel revascularization, or stroke) or bleeding. Additional prespecified safety end points included the rates of acquired thrombocytopenia at 30 days, and stent thrombosis at 30 days and 1 year. RESULTS: Net adverse clinical events at 30 days occurred in 65 patients (8.8%) of 735 who were treated with bivalirudin compared with 96 patients (13.2%) of 729 treated with heparin (relative risk [RR], 0.67; 95% CI, 0.50-0.90; difference, -4.3%, 95% CI, -7.5% to -1.1%; P = .008); and 124 patients (17.0%) of 730 treated with heparin plus tirofiban (RR for bivalirudin vs heparin plus tirofiban, 0.52; 95% CI, 0.39-0.69; difference, -8.1%, 95% CI, -11.6% to -4.7%; P < .001). The 30-day bleeding rate was 4.1% for bivalirudin, 7.5% for heparin, and 12.3% for heparin plus tirofiban (P < .001). There were no statistically significant differences between treatments in the 30-day rates of major adverse cardiac or cerebral events (5.0% for bivalirudin, 5.8% for heparin, and 4.9% for heparin plus tirofiban, P = .74), stent thrombosis (0.6% vs 0.9% vs 0.7%, respectively, P = .77), acquired thrombocytopenia (0.1% vs 0.7% vs 1.1%; P = .07), or in acute (<24-hour) stent thrombosis (0.3% in each group). At the 1-year follow-up, the results remained similar. CONCLUSIONS AND RELEVANCE: Among patients with AMI undergoing primary PCI, the use of bivalirudin with a median 3-hour postprocedure PCI-dose infusion resulted in a decrease in net adverse clinical events compared with both heparin alone and heparin plus tirofiban. This finding was primarily due to a reduction in bleeding events with bivalirudin, without significant differences in major adverse cardiac or cerebral events or stent thrombosis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01696110.

[Analyses of super-response to cardiac resynchronization therapy in patients with congestive heart failure: a multiple center trial].

OBJECTIVE: To evaluate the incidence of super-response and the potential predictors related to super-response after cardiac resynchronization therapy (CRT) in patients with congestive heart failure. METHODS: 190 patients [145 men and 45 women;age: (60.48 ± 11.91) years] underwent CRT between March 2001 and March 2012 were enrolled in this multi-center trial, of which, 54 patients with ischemic cardiomyopathy and 136 patients with non-ischemic cardiomyopathy. These patients were followed up from 6 months to 11 years (mean 58 months) post CRT. RESULTS: Ten patients died within 6 months post CRT, the others were followed up for more than 6 months. At 6-month follow-up, 51 patients were identified as CRT super-responders (28.33%), 75 patients were CRT responders (41.67%) and 29 patients were CRT non-responders (16.11%), and 25 patients were CRT negative responders (13.89%). Super-response occurred more frequently in non-ischemic cardiomyopathy patients, while non-response most commonly occurred in ischemic cardiomyopathy patients (P < 0.05); patients in the negative response group had higher serum creatinine level than other groups (P < 0.05) , and patients in the non-response group and negative response group had higher pulmonary artery pressure than patients in the super-response group (P < 0.05); the average QRS duration was ≥ 160 ms before CRT, and the mean decrease was around 30 ms after CRT in the super-response group while the average QRS duration was 139 ms before CRT, and the mean reduction was around 8 ms after CRT in the negative response group (P < 0.05). LV lead position in the super-response group was usually in the middle and base of the heart, while in the negative response group it was more commonly located in the apex of the heart (P < 0.01) . CONCLUSIONS: LV lead located at the middle and pre-CRT ORS duration ≥ 160 ms are associated with super-response post CRT procedure in this patient cohort.

Long-term clinical effects of programmer-guided atrioventricular and interventricular delay optimization: Intracardiac electrography versus echocardiography for cardiac resynchronization therapy in patients with heart failure.

OBJECTIVES: To compare the haemodynamic results and long-term clinical outcomes of intracardiac electrography (QuickOpt®; St Jude Medical, St Paul, MN, USA) and echocardiography for optimization of atrioventricular (AV) and interventricular (VV) delays in cardiac resynchronization therapy (CRT). METHODS: Patients with CRT devices were prospectively enrolled; AV/VV delays were optimized by either QuickOpt® or echocardiography. Patients in the QuickOpt® group underwent both echocardiography and QuickOpt® optimization, and QuickOpt® AV/VV delays were used to program the CRT. All patients were followed-up for 12 months. RESULTS: In total, 44 patients were enrolled. There was good correlation between AV/VV delays determined by QuickOpt® (n = 20) and echocardiography (n = 24). QuickOpt® was significantly faster than echocardiography-guided optimization. Cardiac function, 6-min walking distance and left ventricular ejection fraction were significantly and similarly improved in both groups at 6 and 12 months compared with baseline. In the QuickOpt® group, left ventricular end diastolic diameters were significantly smaller at 6 and 12 months compared with baseline. CONCLUSIONS: QuickOpt® is a quick, convenient and easy to perform method for optimization of AV and VV delays, with a similar long-term clinical outcome to echocardiography-guided optimization.

[Causes of non-response to cardiac resynchronization therapy in heart failure patients with permanent atrial fibrillation].

OBJECTIVE: To evaluate the long-term effects and analyze causes of non-response to cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). METHODS: Thirty-three patients with HF and AF [29 men, mean age (61 ± 10) years, NYHA class III or IV, left ventricular ejection fraction (LVEF) ≤ 35%, QRS ≥ 120 ms in 31 cases] underwent bi-ventricular pacing (n = 26) or bi-ventricular pacing and atrioventricular node ablation (AVN-ablation, n = 7) were included in this study. Non-response was defined: the increase of left ventricular ejection fraction (LVEF) was less than 15%. Patients were followed-up for 4 years. RESULTS: Six patients died during follow up. Non-responder to CRT was observed in 6 out of 27 survived patients (22.22%). Six out of 7 patients underwent AVN-ablation were in responder group and 1 in non-responder group. Comparing with responder group, the baseline LVEF was significantly higher (37% vs. 32%, P = 0.003), and the history of HF was significantly longer (6.3 years vs. 4.1 years, P = 0.039), pulmonary artery pressure was significantly higher (53 vs. 32 mm Hg, P = 0.027), bi-ventricular pacing percentage (BIVP%) was significantly lower (75.86% vs. 91.73%, P = 0.007) in non-responder group. CONCLUSIONS: Higher LVEF, longer HF history, higher pulmonary artery pressure and lower BIVP% are factors linked with non-responses to CRT in this patient cohort. CRT plus AVN-ablation is associated with high response rate to CRT in this patient cohort.

[Incidence and causes of nonresponse to cardiac resynchronization therapy in patients with congestive heart failure].

OBJECTIVE: To observe the incidence and explore the potential factors of nonresponse to cardiac resynchronization therapy(CRT)in patients with severe chronic congestive heart failure. METHOD: CRT was performed in 119 patients with NYHA function class III-IV and left ventricular ejection fraction ≤ 35% [96 men and 23 women, age (60.5 ± 11.3) years]. RESULTS: Seven patients died for different reasons between 1 - 6 months post CRT and clinical and echocardiographic (Echo) data at 6 months post CRT were analyzed from the remaining 112 patients. The incidence of nonresponse to CRT was 28.57%. Compared to the response group, complete right bundle branch block, longer course of congestive heart failure, higher pulmonary systolic pressure and serum creatinine level and non-optimal target vessels positioning of the left ventricle lead (the great cardiac vein and the middle cardiac vein) were the independent predictors for nonresponse after CRT (all P < 0.05). Compared with nonresponse group, the dosages of digoxin and diuretics used for heart failure were significantly reduced in response group (P < 0.01). CONCLUSIONS: The incidence of nonresponse after CRT was 28.57% in this patient cohort. Higher pulmonary systolic pressure and serum creatinine level and non-optimal target vessels positioning of the left ventricle lead (the great cardiac vein and the middle cardiac vein) were the independent predictors for nonresponse after CRT.

[Anatomy variation of coronary vein system in patients with ischemic heart disease and non-ischemic].

OBJECTIVE: The purpose of this study was to analyze the anatomy variation of coronary vein system in patients with ischemic heart disease (IHD) and non-ischemic heart disease (NIHD). METHOD: Forty-one patients with IHD and 87 patients with NIHD [101 men, mean age (63.5 +/- 10.6) years] were included in this study. RESULTS: Coronary sinuses were successfully cannulated and venographies were obtained in 127 cases. Transvenous LV pacing leads were successfully placed in optimal coronary vein in 123 cases (96.09%). The majority (76.38%) patients had at least one or more vessel abnormalities (thinness, stenosis, tortuousity, lack of lateral marginal vein or postero-lateral vein). The incidence of thin and tortuousity was significantly higher in lateral marginal vein than that in postero-lateral vein (P < 0.05-0.01). The incidence of lack of postero-lateral marginal vein was more frequent than the lack of lateral vein (P < 0.05). The rate of abnormality in both vessels was 25.2%. Incidence of vein lack in male was more frequent than in female (P < 0.05). The thin and tortuousity of vessels in female were more frequent than in male (P < 0.05). The incidence of thin and tortuousity of postero-lateral and abnormality of both vessels was significantly higher in IHD than in NIHD patients (P < 0.05). All coronary sinus myocardial bridges occurred in NIHD. Stenoses of left anterior descending (LAD) and left circumflex (LCX) were mostly associated with abnormality of lateral vessels. CONCLUSIONS: The anatomic variations of lateral and postero-lateral coronary vein were more frequent in this patient cohort. Vein lack in male was more frequent and the thin and tortuousity of vessels were less in male than in female patients. The ratio of vessel abnormality is higher in patients with IHD. Coronary arteries stenosis and position of infarction are associated with anatomic variations of coronary vein system.

Prognostic effects of pulmonary hypertension in patients undergoing cardiac resynchronization therapy.

BACKGROUND: Aim of this study is to investigate the impact of elevated pulmonary artery systolic pressure (PASP) on mortality and the clinical outcome after cardiac resynchronization therapy (CRT). METHODS: Ninety-three patients with heart failure were enrolled into this study, and all of them have been treated by CRT for more than 6 months. Based on the level of preoperative PASP, they were divided into three groups (Group I: PASP>50mmHg, n=29; Group II: 30mmHg0.05. At 6 months after CRT, LVEF increased significantly in all three groups (all P<0.05). CONCLUSIONS: Elevated PASP has no prognostic effects on heart function improvement in patients undergone CRT. However, it was associated with worse LV remodeling and increased death due to aggravation of heart failure.

[Long-term effects and mortality of biventricular pacing therapy in patients with congestive heart failure].

OBJECTIVE: To study the long-term effects and mortality of biventricular pacing therapy in patients with congestive heart failure. METHODS: Twenty-five patients, 18 men and 7 women, aged 34-75 [mean aged of (61.42 +/- 10.36)] years, with a cardiac function of New York Heart Association (NYHA) class III (n = 10) or IV (n = 15) received biventricular pacing therapy from Mar. 2001 to Feb. 2005. The etiologies of heart failure were idiopathic dilated cardiomyopathy (16 cases), hypertensive heart disease (3 cases) and ischemic heart disease (6 cases). Left ventricular end-diastolic dimension (LVEDD) was > 60 mm, Left ventricular ejection fraction (LVEF) was < 0.40 and QRS duration was > 130 ms in all the patients. Heart function parameters were repeatedly measured before and 3 months, 6 months, 1 year, 2 years and 3 years after pacemaker implantation. Mortality was also determined. The average follow up period was (20.88 +/- 11.51) months. RESULTS: (1) Mortality: 5 patients died during follow-up (3 non-cardiac and 1 cardiac sudden death and 1 acute myocardial infarction). (2) The mean 6-min walking distance was increased significantly (P < 0.05) at 3 months to 3 years of follow-up. (3) NYHA class: The cardiac function of all patients improved significantly, with a reduction of mean NYHA class of more than one grade at 3 months to 3 years follow-up. (4) LVEDD: LVEDD reduced significantly (P < 0.05) at 3 months to 3 years follow-up. (5) LVEF: LVEF increased significantly (P < 0.05) at 3 months to 2 years follow-up. LVEF also improved at third year's follow-up, but the difference was not significant statistically. CONCLUSIONS: Cardiac resynchronization, a pacemaker-based therapy for heart failure, may enhance quality of life and heart function and reverse LV remodeling. The long-term effects of treatment were stable, leading to the reduction of mortality from advanced heart failure.

[Percutaneous coronary intervention combined cardiac resynchronization therapy for refractory heart failure secondary to ischemic cardiomyopathy].

OBJECTIVE: To evaluate the efficacy and safety of percutaneous coronary intervention (PCI) combined cardiac resynchronization therapy (CRT) for refractory heart failure secondary to ischemic cardiomyopathy (ICM). METHODS: PCI and CRT were performed in 7 ICM patients confirmed by angiography with NYHA class IV, QRS duration >/= 130 ms in 6 of them, III degrees AVB in 1 patient, fast ventricular heart rate Af in 1 patient, ventricular fibrillation history in 2 patient. All of them had their LVEDD >/= 55 mm, and LVEF

[Protection of renal function during interventional diagnostic or therapeutic procedures in coronary heart disease patients complicated by chronic renal insufficiency].

OBJECTIVE: To evaluate the safety and efficacy of protective measures for renal function during interventional procedures in patients with chronic renal insufficiency. METHODS: Changes in renal function in 90 patients of coronary artery disease with chronic renal insufficiency admitted from January 1994 to July 2002 during intraoperative intervention were analyzed. These patients were divided into three groups: in group A patients underwent coronary angiography (SCA) with conventional peri-intervention treatment; in group B patients underwent SCA and treated with low dose dopamine plus saline hydration peri-intervention; in group C patients underwent percutaneous transluminal coronary angioplasty (PTCA) and stenting, and treated with low dose dopamine plus saline hydration during peri-intervention. RESULTS: Coronary intervention was successful in all patients of three groups. Contrast medium-associated nephropathy (CAN) was found in 28 patients after the procedures, and them 11 occurred in group A (36.7%), 5 in group B (16.7%), and 12 in group C (40.0%), respectively. The incidence of CAN was highest in group C, and lowest in group B (P<0.01). All patients recovered and discharged after medical treatment, and no hemodialysis was necessary. Higher incidence of CAN was found in patients with congestive heart failure than patients without heart failure (64.5%, 20/31 cases vs. 13.6%, 8/59 cases; P<0.01), and also higher incidence of CAN was found in diabetic patients than non-diabetic patients (42.6 , 23/54 cases vs. 13.9%, 5/36 cases; P<0.01). CONCLUSION: The patients with coronary artery disease with chronic renal insufficiency are able to tolerate the interventional procedures well with safety and ideal prognosis, if they are properly protected with dopamine and fluid during the procedure.