Concordant improvements in coronary flow reserve and ST-segment resolution during percutaneous coronary intervention for acute myocardial infarction: a benefit of postconditioning.

OBJECTIVE: To assess the effect of ischemic postconditioning on indices of coronary microvascular function during percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI). BACKGROUND: Myocardial tissue level perfusion remains suboptimal in many patients with STEMI despite restoration of antegrade flow in the epicardial coronary artery. METHODS: Twenty-four patients with an evolving anterior STEMI were randomized to undergo a previously-validated ischemic postconditioning protocol or usual care during PCI. The extent of resolution of ST segment elevation along with Doppler-tip catheter velocimetry was used as indices of myocardial reperfusion and microvascular function, respectively. RESULTS: Postconditioned patients exhibited a greater, and therefore more rapid, extent of ST segment resolution (postconditioning, 70% +/- 15%; control, 48% +/- 16%; P = 0.0002) by the end of the procedure. Postconditioned patients also exhibited a greater hyperemic coronary vasodilator response at the completion of the procedure (coronary flow velocity reserve, CFVR: postconditioning, 2.2 +/- 0.1; control, 1.5 +/- 0.1; P < 0.0001). The end-procedure CFVR was directly related to the extent of the ST segment resolution (r = 0.85) but inversely related to the absolute magnitude of ST segment elevation at end procedure (r = -0.76). Peak serum creatine kinase was significantly lower in postconditioned patients (postconditioning, 1,524 +/- 435 IU/l; control, 1,862 +/- 561 IU/l; P = 0.03). CONCLUSIONS: Ischemic postconditioning, as described, can be expeditiously performed during PCI for STEMI. Concordant changes in coronary flow reserve and ST segment resolution, measures of microcirculatory function, and myocardial perfusion, were greater in postconditioned patients.

Left atrial inflow propagation rate: a new transesophageal echocardiographic index of preload.

We postulated that the rate of blood propagating into the left atrium from the left upper pulmonic vein would be a useful measure of pulmonary capillary wedge pressure (PCWP). In 23 adult patients who were critically ill (ie, study group) and receiving mechanical ventilation, color M-mode multiplane transesophageal echocardiography was used to measure left atrial inflow propagation rate (LAIF-PR) as a potential index of PCWP measured by right heart catheterization. LAIF-PR was measured in systole and diastole as the slope of the color M-mode signal entering the left atrium from the left upper pulmonic vein. Correlation with PCWP was good for systolic (r = -0.847, P < .0001) and diastolic (r = -0.78, P < .0001) LAIF-PR. The reliability of univariate linear regression equations derived from the study group was tested in 29 subsequent patients (ie, testing group). Measured PCWP was accurately estimated within 5 mm Hg in 85% (22 of 26 patients) and 68% (17 of 25 patients) of the testing group by systolic and diastolic LAIF-PR, respectively. Color M-mode transesophageal echocardiography-derived LAIF-PR, particularly in systole, is a promising new index to estimate PCWP in patients who are critically ill.

Left atrial inflow propagation rate derived by transesophageal color M-mode echocardiography is a promising index of preload.

BACKGROUND: Pulmonary capillary wedge pressure (PCWP) is a useful index of preload and an important determinant of cardiac function. HYPOTHESIS: We postulated that the rate of blood propagating into the left atrium (LAIF-PR) would be a useful measure of PCWP in critically ill patients. METHODS: Fifty-two critically ill patients (36 men/16 women) receiving mechanical ventilation were studied by multiplane transesophageal echocardiography (TEE). Left atrial inflow propagation rate was measured in systole and diastole as the slope of the color M-mode signal entering the left atrium from the right upper pulmonic vein. RESULTS: Systolic and diastolic LAIF-PRs were feasible in 49 and 44 patients, respectively. Mean (+/- 1 standard deviation) LAIF-PR in systole was 40 +/- 26 cm/s (range 11-132) and in diastole 34 +/- 22 cm/s (range 5-102). Negative correlations with PCWP (mean 19 +/- 9 mmHg; range 3-40) were good for LAIF-PR in systole (r = -0.71, standard error of estimate [SEE] = 6 mmHg; p < 0.0001) and diastole (r = -0.71, SEE = 6 mmHg; p < 0.0001). Mean ejection fraction was 52 +/- 22% (range 15-88) and cardiac output was 6.97 +/- 3.52 l/min (range 2.26-17.93). Multivariate regression showed PCWP as the only independent predictor of systolic (p < 0.0001) and diastolic (p < 0.0001) LAIF-PR among age, heart rate, cardiac output, ejection fraction, or left atrial diameter. CONCLUSIONS: Left atrial inflow propagation rate derived by color M-mode TEE aligned with the right upper pulmonic vein is a promising new index of preload. Future studies addressing the determinants of LAIF-PR, such as left atrial compliance, are needed.

Transesophageal echocardiography impacts management and evaluation of patients with stroke, transient ischemic attack, or peripheral embolism.

The relative impact of transesophageal echocardiography (TEE) on the management of patients with specific embolic events, namely nonhemorrhagic cerebrovascular accident (CVA), transient ischemic attack (TIA), or peripheral embolism is controversial. The impact of TEE in 234 adult subjects with CVA (n = 141), TIA (n = 59), or peripheral embolism (n = 34) was determined. TEE was diagnostic of a potential embolic source in 61%, 51%, and 62% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). TEE results changed medication or surgical treatment in 32%, 22%, and 32% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). Anticoagulation was started on the basis of TEE findings in 11%, 12%, and 18% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). In 77% of all patients, TEE findings confirmed as appropriate the empiric decision made prior to TEE, to anticoagulate (60%; 12/20) or not to anticoagulate (79%; 168/214). These data demonstrate that TEE findings have a significant and similar impact on the clinical management of patients with various types of potential embolism. Future studies addressing the effectiveness of treatment, guided by TEE findings, in the prevention of recurrent embolic events are needed.

Síndromes coronarios agudos e inhibidores de las glicoproteínas IIb IIIa / Acute coronary Syndromes and inhibitors of the II b, IIIa glycoproteins

El papel de las plaquetes en la protegénesis de los síndromes coronarios agudos es cada vez más evidente. El manejo farmacológico de los mismos era inicialmente orientado a contrarestar un proceso trombotico fibrino-específico sin considerarse la importante participación de las plaquetas en la fisiopatología de los mismos. Desde 1994 se integran al tratamiento los inhibidores de las glicoproteínas IIb IIIa como antiplaquetarios específicos, obteniéndose una discriminación significativa en la morbi-mortalidad cardio vascular. Queremos presentar nuestra experincia preliminar con el uso de estos fármacos en pacientes de alto riesgo

Balón de contrapulsasión Intra-aórtico (BCIA), una alternativa en el manejo del paciente cardiológico críticamente enfermo / Intra- aortic balloon pumping (BCIA) one alternative in the management of sick cardiac patient

El Balón de contrapulsación Intra-aórtico (B.C.I.A.)es un equipo auxiliar de soporte cardiocirculatorio, cuya correcta indicación y utilización le proporcionará ...

Angioplastía primaria en el manejo del infarto agudo al miocardio, experiencia inicial en Panamá / Primary angioplasty in the management of acute myocardial infarctation, initial experience in Panama

En los últimos años se han redoblado los esfuerzos para disminuir y en el mejor de los casos evitar el daño al músculo cardíaco durante el infarto agudo. Las drogas trombolíticas han contribuido positivamente al respecto. Sin embargo, nace la necesidad de buscar formas alternas de tratamiento que proporcionen un más rápido y efectivo restablecimiento de la circulación coronaria. Nos referimos a la Angioplastía Primaria como tratamiento inicial del infarto agudo. Presentamos los primeros 16 casos con infarto agudo al miocardio en curso, tratados con Angioplastía Primaria, 15 de 16 pacientes evolucionaron en forma satisfactoria, sin complicaciones del infarto que al procedimiento de angioplastía per-se. De esta manaera reafirmamos la utilidad de esta nueva forma de tratamiento, planteando una alternativa terapéutica adicional en beneficio de los pacientes que están sufriendo un infarto agudo al miocardio.