Vitamin D deficiency and functional response to CRT in heart failure patients.

BACKGROUND: Vitamin D deficiency has been associated with a poor outcome in patients with heart failure (HF). We examined the role of vitamin D in the response of HF patients to cardiac resynchronization therapy (CRT). METHODS: The study comprised 50 patients (30 men and 20 women) with HF undergoing CRT implantation who were prospectively enrolled. Response to CRT was defined as a combination of ≥15% reduction in left ventricular end-systolic volume (LVESV) and ≥10% improvement in the 6­Minute Walk Test within 6 months. Patients were grouped based on their levels of vitamin D prior to CRT implantation. Clinical and echocardiographic examinations were performed prior to and 6 months after the procedure. RESULTS: Of the patients, 11 (22%) failed to respond to CRT; two patients died within 6 months and an additional nine patients showed no improvement in the 6­Minute Walk Test and no reduction in their baseline LVESV. A comparison was made between 25 patients with sufficient levels of vitamin D and 25 patients with insufficient levels. Nine patients (36%) in the "insufficient" group and two patients (8%) in the "sufficient" group failed to respond to CRT implantation (p = 0.037). CONCLUSION: Adequate serum concentrations of vitamin D play a significant role in improving the functional status of patients with systolic HF following CRT implantation.

Radiation exposure levels according to vascular access sites during PCI : A prospective controlled study.

BACKGROUND: We previously showed that using the radial artery access site as opposed to the femoral artery site decreases the radiation exposure of patients during coronary artery interventions. The objective of this study was to compare radiation exposure levels of the operating physician during coronary interventions when incorporating both radial and femoral artery approaches. METHODS: The study assessed all coronary angioplasties performed in a major metropolitan general hospital. The study design was prospective and observational, in which we measured the radiation exposure of the patient and the operator. Measurements of radiation levels were made using an electronic personal dosimeter (Diamentor® E2-DAP) at the radial and at the femoral artery access sites. An interventional cardiologist operator performed all the percutaneous coronary interventions (PCI) using a single-plane angiography unit via both femoral and radial artery approaches. RESULTS: Data from 252 PCIs were recorded. The mean physician radiation exposure levels from the femoral access site and the right radial access site were 40.5 ± 20.2 µSv and 47.5 ± 26.5 µSv, respectively (p < 0.02). There was a strong correlation between physician and patient radiation exposure levels. However, there was no correlation between patient body mass index and radiation exposure levels. CONCLUSION: We found significantly higher physician radiation exposure levels with the radial artery than with the femoral artery access site.

Effect of remote ischemic postconditioning during thrombolysis in STEMI.

BACKGROUND: Remote ischemic postconditioning (RIPC) is suggested to protect the myocardium against ischemia in various settings. However, the effect of RIPC in patients with acute ST-elevation myocardial infarction (STEMI) who undergo thrombolysis has yet to be examined. PATIENTS AND METHODS: In this single-center, randomized controlled trial, we examined the effect of RIPC on the resolution of ST-segment elevation (STR) in response to thrombolysis. Patients in the RIPC group had three cycles of 5­min cuff inflation followed by 5­min deflation to the upper arm. RESULTS: The study comprised 78 patients (15 women), of whom 41 were randomized to the RIPC group and 37 to the control group. STR occurred in 61% of the patients in the RIPC group, while it was detected only in 35% of controls (p = 0.026). Although STR was more common in the RIPC group, there was no difference in the extent of ΣCK-48 h between the two groups. Furthermore, the length of hospital stay and the frequency of adverse events were similar between the RIPC and control groups. CONCLUSION: RIPC during thrombolytic therapy in STEMI was associated with a higher frequency of STR. However, it did not affect enzymatic infarct size or the frequency of adverse events. (Clinical trial registration number: IRCT2014011916229N2.).

Operator radiation exposure during transradial coronary angiography : Effect of single vs. double catheters.

BACKGROUND: The right radial artery has gained popularity as the preferred access site for coronary angiography. To save time and limit the radiation exposure of operators and patients, newly designed catheters can be used to access both the right and left coronary arteries. The aim of this study was to compare operator radiation exposure between single-catheter (SCA) and two-catheter approaches (TCA). METHODS: In all, 256 patients undergoing diagnostic coronary angiography via the right radial artery in a high-volume medical center were randomized to either the SCA or TCA group. The dose of radiation exposure of the operators was measured by an electronic dosimeter attached to the breast pocket of the operator's apron. The dose-area product and air kerma were used as indices of patient exposure to radiation. The duration of fluoroscopy "beam-on" time, acquisition time, and total duration of the procedure were measured and analyzed for the two groups. RESULTS: Operator radiation exposure was 21.6 ± 11.4 µSv in the SCA group, which was significantly less than 28.0 ± 14.9 µSv in the TCA group. The duration of fluoroscopy was significantly shorter in the SCA group than in the TCA group (152 ± 83 vs. 203 ± 121 s; p < 0.001). Moreover, the total duration of the diagnostic procedure was also shorter in the SCA group compared with the TCA group (9.5 ± 3.2 vs. 11.4 ± 4.0 min; p < 0.001). CONCLUSION: The use of SCA is advantageous over TCA in reducing the exposure of operators to radiation. The shorter duration of fluoroscopy beam-on time and total procedure time may contribute to the lower exposure of operators to radiation.

Predicting outcome after percutaneous balloon mitral commissurotomy : Role of neutrophil-lymphocyte ratio.

BACKGROUND: The value of the neutrophil-lymphocyte ratio (NLR) along with the severity of mitral stenosis (MS) in predicting the outcome of percutaneous balloon mitral commissurotomy (PBMC) has not been studied. PATIENTS AND METHODS: Patients with severe MS undergoing PBMC between 2013 and 2014 in a university hospital were prospectively enrolled. Complete blood cell count was obtained upon admission and NLRs were calculated. The correlations between NLR with immediate PBMC success and restenosis in 1 year were evaluated. RESULTS: In all, 102 patients (80 women) with a mean age of 44.5 ± 13.1 years were enrolled in the study. NLR on admission was 2.6 ± 0.8 and mitral valve area (MVA) was 0.89 ± 0.18 cm2. Patients with a lower MVA at baseline had a higher NLR (p = 0.016). The rate of immediate success was 63 % for PBMC. There was no difference in NLR between patients with regard to early and late failures, as well as those who developed restenosis of the valve. Smaller valve area and the rate of valvular dilatation during PBMC were the only independent factors that predicted early and late failure, respectively. CONCLUSION: NLR at the time of treatment was not useful in predicting procedural outcome or restenosis during follow-up of patients undergoing PBMC.

Pulmonary hypertension in rheumatic mitral stenosis revisited.

BACKGROUND: In patients with mitral stenosis (MS), pulmonary hypertension (PH) is a significant contributor to the associated morbidity. We aimed to study factors associated with the presence of significant PH (sPH) and whether incorporating body surface area (BSA) in the mitral valve area (MVA) would improve the predictive value of the latter. METHODS: The medical records of 558 patients with severe MS undergoing percutaneous balloon mitral commissurotomy were evaluated over a period of 8 years. Factors associated with the presence of significant PH (sPH) defined as mPAP ≥ 40 mm Hg were examined. RESULTS: A total of 558 patients (423 women) were enrolled. Overall, 153 (27%) patients had sPH. Patients with sPH were similar to the rest of the subjects in terms of demographics, body habitus, blood group, and incidence of atrial fibrillation. Among echocardiographic findings, absolute MVA, indexed MVA, and mean transmitral valve gradient were associated with the presence of sPH. Transmitral valve gradient during right heart catheterization had the highest area under the curve for an association with sPH. CONCLUSION: Age, gender, heart rhythm, and blood group were not associated with the presence of sPH in severe MS. The predictive value of the indexed MVA for the presence of sPH was not higher than that of absolute MVA.

Association of ABO blood types with the risk of in-stent restenosis.

OBJECTIVES: To investigate the prevalence of in-stent restenosis (ISR) in patients with various ABO blood types. METHODS: Clinical information from 150 patients with a confirmed diagnosis of ISR and 150 patients with a diagnosis of patent coronary stents in the secondary angiography was collected. Comprehensive demographic and laboratory data, including ABO and Rhesus blood groups, as well as comorbid conditions and vessel and stent characteristics, were recorded for each patient. The association of ABO blood groups with the risk of ISR before and after controlling for coronary risk factors was determined. Categorical data were analyzed with the Chi-square test and numerical values were analyzed with t-tests. Binary logistic regression models were constructed to compare type A and non-A for the frequency of risk factors. RESULTS: A total of 392 stents were implanted in 300 patients. Two hundred and fourteen stents (54.6%) were patent and 178 stents (45.4%) were stenosed. Blood group A was significantly more common in the ISR group (43.3% vs. 28.7%, p=0.03). However, the frequencies of other blood types, as well as Rh antigen, were similar between the two groups. Triglyceride and low-density lipoproteins were the only significantly different variables (221 ± 198 mg/dL vs. 138 ± 76 mg/dL, p<0.001 and 108 ± 36 mg/dL vs. 96 ± 73 mg/dL, p=0.04, in type-A vs. non-A, respectively). After matching for coronary risk factors, there was no difference between A blood type patients and their controls. CONCLUSION: ISR is significantly more prevalent in individuals with the type A blood group. However, this higher association is most likely due to higher atherogenic conditions in patients within this population.

Blood product use in cardiac revascularization: comparison of on- and off-pump techniques.

BACKGROUND: Cardiac revascularization on a beating heart avoids the side effects of cardiopulmonary bypass (eg, neurologic injury, hemodilution, and coagulopathy). We examined perioperative bleeding and use of blood products during coronary artery bypass grafting using either on-pump or off-pump techniques. METHOD: The charts of 126 patients who had coronary artery bypass grafting were reviewed. Data from 66 patients revascularized off pump and 60 patients with cardiopulmonary bypass (on pump) were analyzed using unpaired Student's t test. RESULTS: Average age was 62.5 years in either group. More patients received heparin preoperatively in the off-pump group that resulted in mild elevation of preoperative partial thromboplastin time and activated clotting time (40.4 +/- 2.9 seconds and 150.1 +/- 5.3 seconds, respectively). However, the off-pump group had less perioperative (intraoperative or postoperative) bleeding (2312 +/- 212 mL versus 3251 +/- 155 mL, p < 0.05) and required fewer blood products compared with the on-pump group. Hemoglobin and platelets decreased more in the conventional on-pump group. CONCLUSIONS: Avoiding cardiopulmonary bypass decreases perioperative bleeding and, consequently, reduces the use of blood products after coronary artery bypass grafting, which might result in fewer transfusion-related complications.

Postoperative anisocoria in a patient undergoing endoscopic sinus surgery.

OBJECTIVE: Anisocoria after sinus surgery can be related to serious complications such as intraorbital hematoma or increased intracranial pressure secondary to an expanding hematoma. CASE REPORT: A 51-year-old man underwent endoscopic surgery of sinuses, and developed anisocoria; likely a result of the local spread of cocaine used to provide local anesthesia and vasoconstriction. The localized effect of this anesthetic agent produced a typical picture of nasociliary ganglion block that subsided in a few hours. In the results, the nasociliary nerve block was noticed on recovery from anesthesia with no other neurologic deficit. Ophthalmologic examination demonstrated a short-lasting anisocoria with loss of accommodation and sensory block over the tip of the nose. CONCLUSION: The central spread of the local anesthetics should be considered as a differential diagnosis of unexplained anisocoria, especially when it is associated with loss of corneal reflex.

Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery.

INTRODUCTION: The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients. METHODS: Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome. RESULTS: Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05). CONCLUSIONS: Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.

Alemtuzumab and minimization immunotherapy in kidney transplantation: long-term results of comparison with rabbit anti-thymocyte globulin and standard triple maintenance therapy.

BACKGROUND: Efforts to improve long-term patient and allograft survival have included use of induction therapies as well as steroid and/or calcineurin inhibitor (CNI) avoidance/minimization. METHODS: This is a retrospective review of kidney transplant recipients between September 2004 and July 2009. Immune minimization (group 1; n = 182) received alemtuzumab induction, low-dose CNI, and mycophenolic acid (MPA). Conventional immunosuppression (group 2; n = 232) received rabbit anti-thymocyte globulin, standard-dose CNI, MPA, and prednisone. RESULTS: Both groups were followed up for same length of time (49.4 ± 21.7 months; P = .12). Patient survival was also similar (90% vs 94%; P = .14). Death-censored graft survival was inferior in group 1 compared with group 2 (86% vs 96%, respectively; P = .003). On multivariate analysis, group 1 was an independent risk factor for graft loss (aHR = 2.63; 95% confidence interval [CI], 1.32-5.26; P = .006). Biopsy-proven acute rejection occurred more in group 1, due to late rejections compared with group 2 (7% vs 2%; P < .01 respectively). Graft function was lower in group 1 compared with group 2 at 3 months (49.5 mL/mt vs 70.7 mL/mt, respectively; P < .001) to 48 months (48.6 mL/mt vs 69.4 mL/mt, respectively; P = .04). CONCLUSION: Minimization of maintenance immunosuppression after alemtuzumab correlated with higher acute rejection and inferior graft survival compared with thymoglobulin and conventional triple immunotherapy.

Graft arteriosclerosis and glomerulosclerosis correlate with flow and resistance to machine perfusion in kidney transplantation.

INTRODUCTION: Machine perfusion to preserve kidneys for transplantation has grown over the past decade with demonstrated diagnostic and therapeutic benefits. Flow and resistance patterns are used to predict delayed graft function (DGF) and posttransplant graft survival. Preimplantation biopsies obtained serve a similar role in evaluating kidneys especially if they meet expanded criteria. The reliability of available data is greater if there is a correlation among various forms of assessment. In this study we attempted to study serial pump parameters that might correlate with abnormal findings in preimplantation biopsies and subsequently in outcomes after transplantation. METHODS: Two hundred sixty-eight kidneys were assessed for changes in pump pressures in mm Hg, flow in mL/min, resistance in mm Hg/mL/min, and temperature in °C at 15-minute intervals. Allografts were separated into two groups on the basis of pathology; group 1 showed abnormal (AH) and group 2 normal histology (NH). AH was defined by the presence of glomerulosclerosis in ≥10% of sampled glomeruli or arteriosclerosis affecting at least 10% of the arterial lumens of sampled intrarenal arteries. We assessed discordance between frozen and permanent sections. Measured clinical outcomes included DGF, 1-year graft survival, 1-year serum creatinine and estimated glomerular filtration rate (eGFR). Statistical analysis was performed using a paired Student t test and chi-square analysis. RESULTS: Compared to NH kidneys, those with AH showed uniformly significant lower flow rates and higher resistances during the entire perfusion. Graft pathology did not predict DGF (70% versus 60%, P = .45). However, 1-year graft survival (96.2% versus 80%, P = .07) and eGFR (58 versus 48 mL/min, P = .19) were lower among kidneys with AH, though these matrics did not reach significance. CONCLUSION: Preimplantation biopsy findings correlated with flow and resistance to perfusion. If a discrepancy is evident upon evaluation of a donor kidney, a repeat biopsy is prudent prior to discarding or using the organ.

Effect of increased pressure during pulsatile pump perfusion of deceased donor kidneys in transplantation.

INTRODUCTION: Pulsatile pump perfusion of potential kidneys for transplantation is known to decrease the rate of delayed graft function (DGF) and improve their 1-year survival. Flow and resistance parameters are often used to determine the suitability of kidneys for transplantation. Kidneys with low flow rates are often subjected to higher pressures to improve flow. This study evaluated the effect of higher pump pressures on posttransplant renal function. METHODS: We performed a retrospective analysis of 73 deceased donor kidneys preserved using pump perfusion (LifePort) at our center between May 2006 and September 2009. We calculated the mean pump pressure (MP) for the duration of perfusion of each kidney, using systolic pressure (SP) and diastolic pressure (DP) readings with the following formula: (MP = DP + 1/3 (SP - DP). The kidneys were divided into a low (LP; n = 49) and a high-pressure group (HP; n = 24) based on a MP cutoff value of 23 mm Hg. The two groups were then compared for differences in perfusion dynamics and primary endpoints including DGF and 1-year graft survival. Statistical analysis was performed using paired Student t test and chi-square analysis. RESULTS: The two groups were comparable for donor age, extended criteria, sensitization, and cold ischemic times. They differed significantly in higher initial (0.65 ± 0.4 versus 0.4 ± 0.2, P = .01), average (0.25 ± 0.08 versus 0.18 ± 0.06, P = .0006), and terminal resistance (0.21 ± 0.07 versus 0.17 ± 0.06, P = .008) of HP versus LP kidneys. Flow rates were comparable between the two groups. DGF was higher in HP kidneys (75% versus 40%, P = .006) with similar 1-year graft survival (87.5% versus 89%, P = .7). CONCLUSIONS: Perfusate flow through a kidney can be improved by increasing pressure settings to overcome elevated resistance. This maneuver was not associated with a lower rate of DGF after transplantation. One-year graft survival remained unaffected.

Prognostic utility of hypothermic machine perfusion in deceased donor renal transplantation.

UNLABELLED: Pulsatile pump perfusion of kidney transplants is known to decrease delayed graft function (DGF) and improve 1 year graft survival when compared to static cold preservation. Kidneys with better flow and resistance parameters on perfusion are likely to have a better post transplant function. These parameters are commonly used to evaluate kidneys being considered for transplantation. This study assesses the time frame for a kidney within which it reaches optimal perfusion parameters. All kidneys pumped between 5/2006 and 9/2009 on a Lifeport© kidney transporter at our local organ procurement agency were studied. 190 kidneys were evaluated and then divided into two groups based on whether terminal flows increased or declined after prolonged perfusion. All kidneys were assessed for changes in flow (F), resistance (R) and temperature at 15 minute intervals. Discards, DGF and one year graft survival were noted. The Student paired t test and Chi-square analysis were used to compare data. A multiple logistic regression analysis was performed to study independent predictors of DGF on pump perfusion. RESULTS: For all kidneys, the mean initial flow was 59 ± 35 mL/min which improved to an average flow of 128 ± 38 mL/min with continued perfusion. The maximal flow and terminal flows were 148 ± 51 and 135 ± 38 mL/min respectively. The flows at 2, 4, and 6 hours was 125 ± 41, 128 ± 42 and 130 ± 39 mL/min respectively. Kidneys that improved on continued perfusion had a significantly lower discard rate (20 vs 34% p < 0.05), but a higher incidence of DGF (64 vs 39%, P < .05). One year graft loss (death censored) was comparable in the two groups. (4/42 vs. 3/33, P = .94). Resistance at 2, 4, and 6 hours was predictive of DGF, as was donor anoxia and cerebrovascular accident (CVA) as the cause of death. CONCLUSIONS: Kidneys on pulsatile pump perfusion tend to show improved flows and decreased resistance over time. The average flow for a kidney is reached by 2 hours. Those kidneys that start with lower flow rates that improve after 2 hours with continued perfusion are less likely to be discarded but are still associated with a greater incidence of delayed graft function. Resistance at 2 hours predicts DGF while initial resistance predicts one year graft survival.