A systematic diagnostic and therapeutic approach for the treatment of patients after cardio-pulmonary resuscitation: a prospective evaluation of 212 patients over 5 years.

A literature on systematic treatment protocols for patients after resuscitation for cardiac arrest is lacking. We evaluated a systematic protocol, including ECG, echocardiogram, urgent cardiac catheterisation ("STEMI-like" workflow), CT scans, laboratory findings, IABP, hypothermia, and cMRI, prospectively over 5 years. The primary endpoint was the Cerebral Performance Category Scale (CPCS). During the period from January 2008 to December 2012, 212 patients were included. The mean age was 66.7 years, n = 151 (71.2 %) were male, mean time from the first medical contact to start of catheterisation was 76.6 min, and ventricular fibrillation (VF) was present in n = 99 (46.7 %). A significant coronary artery stenosis was seen in n = 130 (61.3 %), PCI was performed in n = 101 (47.6 %), an ACS was found in n = 100 (47.2 %), n = 91 patients (42.9 %) had another cardiac cause, an extra-cardiac cause was found in n = 12 (5.7 %, mostly a cerebral process), and in 9 patients (4.3 %), no cause was identifiable. A significant difference in mortality was found for patients with TIMI flow 2/3 vs. 0/1 (65.4 vs. 95.7 %, p < 0.01). The difference of intra-aortic balloon pumping vs. no pumping was not significant, performing hypothermia reduced mortality significantly (52.7 vs. 68.2 %, p = 0.04). The survival rate was n = 76 (35.9 %), a CPCS of 1/2 was reached in n = 68 pts (32.1 %), patients with ongoing resuscitation had a 100 % mortality (n = 41), and VF had a lower mortality (54.6 vs. 72.6 %, p < 0.01). A systematic algorithm may improve the outcome of patients after reanimation compared with classically reported outcomes. The data are hypothesis generating for further studies.

Interventional therapy of bifurcation lesions: a TIMI flow-guided concept to treat side branches in bifurcation lesions--a prospective randomized clinical study (Thueringer bifurcation study, THUEBIS study as pilot trial).

BACKGROUND: Treatment of bifurcations is a complex problem. The clinical value of treating side branches is an unsolved problem in the field of interventional cardiology. METHODS AND RESULTS: We initiated a prospective randomized controlled trial. One hundred and ten patients with bifurcations were randomly assigned to 2 arms: Stenting of the main branch (MB, Taxus-stent, paclitaxel-eluting stents) and mandatory side branch (SB) percutaneous coronary intervention (PCI; kissing balloons) with provisional SB stenting (therapy A), or stenting of the MB (paclitaxel-eluting stents) with provisional SB-PCI only when the SB had a thrombolysis in myocardial infarction flow <2 (therapy B). The primary end point was target lesion revascularization. The mean ages were 66.8 years (A) versus 65.1 years (B, P=0.4), 71.4% (A) versus 77.8% were men (P=0.4), patients with diabetes were present in 25.0% versus 25.9% (P=0.9). The MB was left anterior descending artery in 80.4% versus 81.5% (A versus B, P=0.9). The SB-PCI and kissing balloon-PCI were performed according to the study protocol in 82.1%/73.2% versus 16.7%/13.0% (P<0.05 for both), while changing of the intended therapy was necessary in 17.9% versus 16.7% (A versus B, P=0.9). A final thrombolysis in myocardial infarction flow 3 (MB) was reached in all patients (groups A and B), final thrombolysis in myocardial infarction flow 3 (SB) was observed in 96.4% versus 88.9% (A versus B, P=0.3). Radiation time (min) and contrast medium (mL) were 14.2/210 (group A) versus 7.8/151.6 (group B; P for both <0.05). Six month - follow up: major adverse cardiac events was 23.2% (A) versus 24.1% (B, P=0.9), target lesion revascularization was 17.9% (A) versus 14.8% (B, P=0.7), and late lumen loss (MB) was 0.2 mm (A) versus 0.3 mm (B, P=0.5). In group B, no PCI of the SB was done during follow up. CONCLUSIONS: A simple strategy using paclitaxel-eluting stents with only provisional SB-PCI may be of equal value to a more complex strategy with mandatory SB-PCI. Clinical Trial Registration- URL: http://www.controlled.trials.com. Unique identifier: ISRCTN22637771.

Outcome in a large unselected series of patients with acute pancreatitis.

BACKGROUND/AIMS: The objective of this study was to assess the outcome in a large unselected population of patients with acute pancreatitis treated at a single university center. METHODOLOGY: We performed a retrospective analysis of 364 patients with acute pancreatitis and evaluated outcome, morbidity and mortality in relation to different treatment modalities. RESULTS: 238 patients suffered from interstitial-edematous pancreatitis, 126 patients from the necrotizing form. ICU treatment was necessary for 174 patients (48%). Minimally-invasive CT guided drainage techniques were used in 73 patients (20%) with pancreatic necroses but also in seven patients with edematous pancreatitis (2%), which showed extrapancreatic tissue necrosis. The overall hospital mortality was 14% (5.5% for patients with edematous pancreatitis vs. 30% for patients with necrotizing pancreatitis). CONCLUSIONS: In patients with the edematous form a small subpopulation showed peripancreatic tissue necrosis without necrosis of the pancreas itself, which was related to higher mortality rates than expected for patients with edematous pancreatitis. Regarding therapeutic procedures interventional treatment modalities should be considered as alternative treatment modalities.

Tako-Tsubo-like cardiomyopathy: specific ECG findings, characterization and clinical findings in a European single center.

OBJECTIVES: A newly discovered heart syndrome mimicking acute coronary syndrome has been termed 'Tako-Tsubo cardiomyopathy' (TTC). Differentiation from acute myocardial infarction using the ECG is an important issue in clinical practice. METHODS: We retrospectively analyzed patients admitted for cardiac catheterization between September 2003 and September 2006. RESULTS: From 26,593 cardiac catheterization procedures, we identified 21 patients with suggested TTC (0.08%). Trigger mechanisms were present in 38.1%; all patients had elevated troponin levels (mean 3.9 ng/ml). Median age was 68.4 years; 90.5% were female. Hypertension was seen in 85.7% and atrial fibrillation in 19.1%. Specific ECG findings related to a TTC are: a mild elevation of the ST segment arising from the S curve of the QRS complex, where the maximum ST segment elevation at the basis of the T wave is <1.5 mm, T-wave inversion, absence of ST segment depression and a summated amplitude of the S curve in V1 plus R in V6 <1.5 mV. An intraventricular gradient was seen in 9.5%; coronary atherosclerosis was detected in 57.1%. Follow-Up Data: Mean follow-up was 13.2 months. 47.6% were free from angina or dyspnea, most of the patients received beta-blockers/ACE inhibitors (76.2%). One patient had a sudden cardiac death (4.8%), 1 patient became an implantable cardioverter-defibrillator primarily due to resuscitation. CONCLUSION: TTC is a rare syndrome mimicking acute coronary syndrome that shows a specific ECG pattern and does not appear to be an unambiguously benign disease.

A new vascular closure device for the transradial approach: the D Stat Radial system.

BACKGROUND: The transradial approach is associated with low complication rates. The D Stat Radial vascular closure system offers hemostatic pressure locally at the puncture site with residual venous flow. METHODS: We prospectively included 113 consecutive patients presenting between August 2006 and December 2006. Diagnostic coronary procedures were performed using 4 Fr or 5 Fr sheaths, while 6 Fr devices were used for PCI. In every case at least 5.000 IU heparin was given. Compression with the retention strap was planned for approximately 3 hours before the pad was fixed using a medical strip. All data were entered into a database after a two-dimensional ultrasound examination study of the puncture site. RESULTS: The mean age was 65 years (+/-SD 10.3), with 62% being male. Patients presenting with acute coronary syndrome amounted to 6.2%, where 5r F sheaths were usually used with these patients (64.6%). PCI was carried out in 21.2% of cases. The system was applied successfully in all patients. The mean duration of compression was 4.6 hours (+/-SD 1.4). Bleeding after removal of the system occurred in 18.6% of cases, which resulted in prolonged compression in 17.7%. A hematoma >5 cm was seen in 4.4% of the sample. Ultrasound examinations revealed closure of the radial artery in 6.2%. CONCLUSIONS: We conclude that this new device operates efficiently, but bleeding occurred in 18.6%. Compression time should be extended to 6 hours.

Acute coronary syndrome without significant stenosis on angiography: characteristics and prognosis.

The characterization of patients who have acute coronary syndrome (ACS) without critical stenosis is unclear. First, we wanted to learn more about the angiographic and demographic characteristics of patients with non-ST-segment-elevation myocardial infarction who were not in need of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Second, we wanted to look for further cardiac events during follow-up. We retrospectively analyzed all patients with ACS plus ischemic-marker elevation from May 2002 through September 2005. Follow-up was obtained primarily by telephone interviews. Of the 1,437 ACS patients who were screened, 127 (8.8%) had noncritical stenosis (study group), and 509 (35.4%) had sufficient stenosis (>50%) to warrant PCI (control group). Patients with noncritical stenosis (< or =50%) were significantly younger, were more frequently women, and had fewer risk factors. Myocardial infarction or PCI/CABG occurred in no patients with noncritical stenosis (follow-up, 12.2 mo) and in 5.1% or 16.1% (respectively) of patients with critical stenosis (follow-up, 11.1 mo; P <0.05 for revascularization). Cardiac death was more likely in patients without critical stenosis, but insignificantly so (2.4% vs 1.8%, P=0.6). SUBANALYSIS: Of patients without critical stenosis, 52.8% had smooth coronary arteries, and 47.3% had mild-to-moderate atherosclerosis (stenosis < or =50%). Follow-up revealed no deaths in the 1st subgroup and 3 cardiac deaths (5%) in the 2nd (P=0.06). We conclude that the prognosis of patients without significant stenosis was significantly better in regard to revascularization, but statistically the same in regard to mortality.