Nonpharmacological interventions for 'no-option' refractory angina patients.

Refractory angina pectoris (RAP) defined as chronic anginal chest pain because of coronary artery disease (CAD) is a major problem. The increase in the number of patients with RAP in recent years is because of the increasing aging population and improved survival rates among patients with CAD. Management of patients with RAP is often extremely challenging. In this review, we present several interventional approaches for RAP, including device therapies, lifestyle intervention, and cell therapies. Some of these treatments are currently used in the management of RAP, whereas other treatments are under investigation.

The Coronary Sinus Reducer Stent for the Treatment of Refractory Angina Pectoris: From the Conception of Innovation to Clinical Application.

The Neovasc Coronary Sinus Reducer Stent (CSRS) was developed for the treatment of patients who continue to suffer from disabling symptoms despite optimal medical therapy. This patient population with refractory angina symptoms is expected to grow, since life expectancy of individuals with atherosclerotic coronary artery disease is increasing. In this paper, we discussed the development of a novel device the CSRS and the upside-down strategy to rebuild a retrograde coronary pressure that was attenuated by the atherosclerotic disease.

Mechanical alternatives to the human heart: intracorporeal assist systems and total artificial heart.

The currently available intracorporeal assist systems and total artificial heart provide long-term support for patients terminally ill with congestive heart failure, often in an out-of-hospital environment. While they are currently widely used mainly as a long-term bridge to heart transplantation, their inherent risks of infection or stroke are prompting interest in future devices that will be smaller, fully implantable and hopefully stroke-free. These devices will be described in the last part of this review.

Mechanical alternatives to the human heart: paracorporeal assist systems.

The currently available paracorporeal assist systems provide reliable short or long-term mechanical assistance to the failing heart, albeit necessitating continuous hospitalization. The intracorporeal assist systems, which provide out of hospital assistance, will be described in the next part of this review.

Minimally invasive video-assisted mitral and aortic valve surgery--our initial clinical experience.

BACKGROUND: After the introduction of endoscopic techniques to other surgical fields like general surgery, gynecology and thoracic surgery, cardiac surgeons sought their own methods of using minimally invasive techniques. OBJECTIVES: To examine whether this approach is less invasive and yields better results, more desirable cosmetic results, and a more rapid and complete rehabilitation, maintaining safety, efficacy, and outcome equivalent to those of more established procedures, such as median sternotomy. METHODS: From January 2000 to July 2001, 22 patients underwent video-assisted port-access mitral or aortic valve repair or replacement with the Heartport system in our department, and one underwent closure of atrial septal defect. RESULTS: Intraoperative transesophageal echocardiography revealed excellent functional results. Total operating room time, perfusion time, and cross-clamp time with this technique decreased with our growing experience and remains stable. There were no intraoperative reversals to mid-steronomy, no mortalities, and only one complication 24 hours after surgery. CONCLUSIONS: Thoracoscopic assisted cardiac surgery (via port access) provides all the advantages of minimally invasive surgery, accelerates recovery, decreases pain, and maintains overall surgical efficacy, while avoiding the complications and pathology of mid-sternotomy. For appropriate patients, this is the method of choice in our department.

Severe acidosis does not predict fatal outcomes in intensive care unit patients: a retrospective analysis.

PURPOSE: Severe acidosis is a potentially life-threatening acid-base imbalance. The outcome of patients with severe acidosis has only been anecdotally described. We therefore assessed the discharge rate of such patients from the intensive care unit (ICU) and survival time after the event. METHODS: A retrospective evaluation of medical records of patients admitted to the ICU of Tel Aviv Medical Center between 2005 and 2010, in whom arterial blood pH less than 6.8 was documented during their ICU stay, was performed. RESULTS: Twenty-eight patients were suitable for study entry. Septic shock was the most common underlying medical condition (33%). Nine (32.1%) patients were either discharged alive or survived for at least 30 days in the ICU after their arterial blood pH measurement was less than 6.8. More than a quarter of the patients with life-threatening acidosis (n = 8; 28.6%) were discharged home and returned to their prehospitalization daily activity. Mean follow-up period for these patients was 132 ± 111 weeks. Multivariate analysis identified hyperkalemia, Acute Physiology and Chronic Health Evaluation II score, and Glasgow Coma Scale as determinants for ICU death after severe acidosis. CONCLUSIONS: A significant number of patients can outlast severe acidosis and return to their prehospitalization status. Larger studies are needed to define the patient population most likely to benefit from aggressive resuscitation efforts during severe acidosis.

Coronary sinus reducer stent for the treatment of chronic refractory angina pectoris: a prospective, open-label, multicenter, safety feasibility first-in-man study.

OBJECTIVES: This study sought to evaluate the safety of the Coronary Sinus Reducer (Neovasc Medical, Inc., Or Yehuda, Israel) as a potential alternate therapy for patients with refractory angina who are not candidates for conventional revascularization procedures. BACKGROUND: Increased coronary sinus (CS) pressure can reduce myocardial ischemia by redistribution of blood from nonischemic to ischemic territories. The Coronary Sinus Reducer is a percutaneous implantable device designed to establish CS narrowing and to elevate CS pressure. In preclinical experiments, implantation of the Reducer was safe and was associated with improved ischemic parameters. In the present study, the safety and feasibility of the Coronary Sinus Reducer was evaluated in patients with refractory angina who were not candidates for revascularization. METHODS: Fifteen coronary artery disease patients with severe angina and reversible ischemia were electively treated with the Reducer. Clinical evaluation, dobutamine echocardiography, thallium single-photon emission computed tomography, and administration of an angina questionnaire were performed before and 6 months after implantation. Cardiac computed tomography was performed 2 days and 6 months after implantation. RESULTS: All procedures were completed successfully. No procedure-related adverse events occurred during the periprocedural and the follow-up periods. Angina score improved in 12 of 14 patients. Average Canadian Cardiovascular Society score was 3.07 at baseline and 1.64 at follow-up (n = 14, p < 0.0001). Stress-induced ST-segment depression was reduced in 6 of 9 patients and was eliminated in 2 of these 6 (p = 0.047). The extent and severity of myocardial ischemia by dobutamine echocardiography and by thallium single-photon emission computed tomography was reduced (p = 0.004 [n = 13] and p = 0.042 [n = 10], respectively). CONCLUSIONS: Implantation of the Coronary Sinus Reducer is feasible and safe. These findings, along with the clinical improvement observed, support further evaluation of the Reducer as an alternative treatment for patients with chronic refractory angina who are not candidates for coronary revascularization.

Treatment of deep sternal wound infections post-open heart surgery by application of activated macrophage suspension.

Postoperative sternal wound infection remains a significant complication and generally causes considerable morbidity and mortality. Macrophages play a major role in the process of wound healing. In order to evaluate the efficacy of local injection of activated macrophage suspensions into open infected sternal wound space, a retrospective case-control study was conducted. Sixty-six patients with deep sternal wound infection treated by activated macrophages (group 1) and 64 patients with deep sternal wound infection treated by sternal reconstruction surgery with various regional flaps (group 2), were matched for gender, age, and risk index. In up to 54 months of follow-up of group 1, 60 patients (91%) achieved complete wound closure. Two (3%) late deaths occurred unrelated to the procedure. Mortality rate in group 2 was 29.7% (19/64). Duration of hospitalization was 22.6 days in group 1 vs. 56.2 days in group 2. Patients with deep sternal wound infection following open heart surgery that were treated by activated macrophages had significantly less mortality as well as significant reduction of hospitalization in comparison to the surgically treated group. These results illustrate the advantages of using a biologically based activated macrophage treatment.