Safety and efficacy study of the wound care 360° SiteSeal® vascular closure device in percutaneous cardiac catheterization procedures.

OBJECTIVES: Vascular access site complications after percutaneous transfemoral cardiovascular procedures remain a common cause of morbidity and mortality. We evaluated the SiteSeal® VCD for achieving hemostasis following diagnostic cardiac catheterization. METHODS: We conducted a prospective case control single center study to assess the safety and efficacy of SiteSeal® VCD compared to standard manual compression following diagnostic cardiac catheterization. Forty patients were enrolled in study to receive either SiteSeal® device or manual compression (20 in each group). RESULTS: Patients in the SiteSeal® group achieved hemostasis in a significantly shorter time (4 ± 2.4 vs. 19 ± 2.4 min, P < 0.001), had shorter time from hemostasis to ambulation (95 ± 44 vs. 388 ± 63 min, P < 0.001) and significantly earlier device deployment to discharge time compared to the manual compression group (4.7 ± 1.1 vs. 8.9 ± 4.8 h, P = 0.001). There was one non-major bleeding event in the SiteSeal® group which occurred >24 h after discharge from the hospital and was managed conservatively. In the remaining device patients, there was no clinical or Doppler ultrasound evidence of major or minor vascular complication with good overall patient comfort at discharge, 7 days and 30 days follow-up. CONCLUSIONS: In this first clinical experience, the SiteSeal® VCD achieved safe and efficient hemostasis, allowed for earlier ambulation and faster discharge compared to manual compression.

Perioperative Stroke and Mortality After Surgical Aortic Valve Replacement: A Meta-Analysis.

OBJECTIVE: Perioperative stroke rate after surgical aortic valve replacement (SAVR) varies between 1.3% and 6.2%, whereas the operative mortality ranges between 1% and 16.4%. The aim of this study was to determine whether perioperative stroke is a risk factor for operative mortality after SAVR by performing a meta-analysis of relevant studies. MATERIALS AND METHODS: PubMed, EMBASE, and Web of Science databases were searched to retrieve relevant literature. Screening of the articles was done independently on the basis of predetermined criteria. Data from the relevant studies were extracted and a random effects model was used to calculate the odds of mortality among patients with perioperative strokes after aortic valve replacement compared with those without such strokes. Subgroup analyses of patients (1) aged above and below 70 years and (2) undergoing isolated valve replacement procedure were performed. Metaregression to check for association of effect estimate and (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation was performed. RESULTS: Statistical analyses using a random effects model showed that patients with perioperative strokes had 4.74 times greater odds for operative mortality after SAVR, independent of the following covariates: (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation. CONCLUSIONS: Patients with perioperative strokes after SAVR have nearly 5 times greater odds of experiencing operative mortality compared with those without. Thus, perioperative strokes are associated with increased risk of early mortality and require further examination of preventive strategies.

Perioperative Stroke, In-Hospital Mortality, and Postoperative Morbidity Following Transcatheter Aortic Valve Implantation: A Nationwide Study.

BACKGROUND AND PURPOSE: Perioperative stroke is a significant complication of transcatheter aortic valve implantation (TAVI). This study aimed to quantify perioperative stroke as an independent risk factor for in-hospital mortality and postoperative morbidity in patients receiving TAVI. METHODS: A retrospective cohort study was conducted using the National Inpatient Sample. Patients undergoing TAVI during 2012 and 2013 were identified using diagnostic codes of International Classification of Diseases, ninth revision. Univariate and multivariate analyses were performed using patient demographics and comorbidities to identify predictors of mortality and morbidity, defined by a length of stay of >14 days and/or discharge to a place other than home. RESULTS: Data were obtained from 7,556 patients undergoing TAVI during 2012 and 2013. The incidence rates of mortality and morbidity were 4.57 and 71.12%, respectively. Perioperative stroke was an independent risk factor for mortality [odds ratio (OR)=3.182, 95% confidence interval (CI)=1.530-6.618, p=0.002], as were infection (OR=17.899, 95% CI=9.876-32.440, p<0.001) and pericardial tamponade (OR=7.272, 95% CI=2.874-18.402, p<0.001). Stroke also predicted morbidity (OR=5.223, 95% CI=2.005-13.608, p=0.001), which was also associated with age, being female, being Asian, moderate and high Van Walraven scores (VWR), and infection. CONCLUSIONS: In conclusion, perioperative stroke was found to be independently associated with in-hospital mortality and postoperative morbidity, as are age and high VWR. Our findings support the use of further preoperative, intraoperative, and postoperative management strategies during TAVI.

Implications of the 2013 ACC/AHA cholesterol guidelines on contemporary clinical practice for patients with atherosclerotic coronary and peripheral arterial disease.

BACKGROUND: Cholesterol management guidelines from the American College of Cardiology/American Heart Association (ACC/AHA-2013) recommend fixed statin dosing (dose depends on age ≤ or >75years) compared to the earlier adult treatment panel III (ATPIII) guidelines which recommended specific low-density lipoprotein-cholesterol (LDL-C) targets. Clinical implications of this recommendation are not known. METHODS: We retrospectively compared cholesterol levels and statin utilization across cohorts with coronary artery disease (CAD) (n=9563), peripheral arterial disease (PAD) (n=596) and CAD+PAD (n=975) by applying both guidelines. The percentage of patients who achieved guideline-specific targets using 2013 ACC/AHA (use of moderate/high intensity statins) or ATPIII guidelines (LDL-C<100mg/dl) was compared between all groups. RESULTS: Using both guidelines, the PAD only group demonstrated lower utilization and lower statin doses than the CAD or CAD+PAD groups. When applying the ACC/AHA guidelines, more patients in the CAD only group (age ≤75 years) were considered at goal as compared to the ATPIII guidelines (92.2% vs. 75%), primarily driven by the group placed on moderate/high intensity statins but had an LDL-C level >100mg/dl. CONCLUSIONS: Application of the ACC/AHA guidelines results in a higher percentage of patients considered to be 'at goal' when compared to the ATP III guidelines without changes in clinical practice. This is due to patients ≤75 years old on adequate statin doses but still have LDL-C levels >100mg/dl, thereby raising concerns that physicians may not pursue alternate LDL reduction strategies since they are now considered at goal despite LDL-C >100mg/dl. Lipid management of PAD patients remains sub-optimal as compared to CAD and CAD+PAD.

Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis.

OBJECTIVE: To investigate the risk factors for postoperative delirium and the impact of delirium on mortality and morbidity following transcatheter aortic valve implantation (TAVI). DESIGN: Patients who underwent TAVI were identified using the International Classification of Diseases, 9th revision clinical modification codes from the National Inpatient Sample database. Statistical analysis of preoperative and perioperative risk factors was done to identify the independent risk factors for delirium after TAVI. SETTING: Multi-institutional. PARTICIPANTS: Patients who underwent TAVI from 2012 to 2013. INTERVENTIONS: TAVI. MEASUREMENTS AND MAIN RESULTS: Over the period of 2 years (2012-2013), 7,566 patients underwent TAVI. The incidence of delirium post-TAVI was 4.57% (345). Age >85 (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.05; p = 0.003), electrolyte abnormalities (OR 1.83; 95% CI 1.17-2.87; p = 0.008), prior neurologic illness (OR 1.67; 95% CI 1.10-3.15; p = 0.01), and weight loss in the hospital (OR 1.77; 95% CI 1.05-2.99; p = 0.03) were independent risk factors for postoperative delirium (POD). Unilateral or bilateral carotid stenosis did not predispose to the development of delirium. POD was an independent risk factor for procedural morbidity (OR 3.29; 95% CI 2.05-5.28; p < 0.001). POD did not increase the risk of in-house mortality after TAVI. CONCLUSION: Age of >85, electrolyte disturbance, pre-existing neurologic disease and weight loss were found to be independent risk factors for delirium. POD was associated significantly with morbidity. Owing to a significant increase in the morbidity, a thorough screening protocol and effective strategies to predict, prevent, and treat postoperative delirium would reduce the cost associated with TAVI.

Perioperative Strokes Following Surgical Correction of Mitral Valves: A Systematic Review and Meta-Analysis.

OBJECTIVE: The primary aim of this meta-analysis was to quantify the impact of perioperative strokes on stroke-related mortality after open mitral valve (MV) procedures were performed. METHODS: An electronic search of the PubMed, Embase, and the Web of Science databases was performed to retrieve articles published up to December 2015, relevant to patients undergoing MV procedures. Data were extracted from the final list of 25 studies to calculate a summary OR for 30-day stroke-related mortality. RESULTS: The stroke rate in the total sample population was 1.62% (73/4,498). The 30-day all-cause mortality rate was 3.51% (158/4,498). The percentage of total deaths caused by stroke was 6.87%. The summary OR of stroke-related mortality following MV procedures was estimated to be 7.22 (95% CI 4.13-12.63, p < 0.0001). A subgroup analysis was done for studies involving concomitant MV surgery and coronary artery bypass grafting. The summary estimate of the subgroup showed an OR of 8.508 (95% CI 1.552-46.622, p = 0.0136). CONCLUSION: Perioperative strokes following open MV procedures may be associated with more than 7 times greater odds of 30-day stroke-related mortality. They appear to be more commonly occurring than what is reported by current literature, making further studies investigating possible mechanisms and preventive measures a priority.

Carotid artery disease and periprocedural stroke risk after transcatheter aortic valve implantation.

OBJECTIVE/BACKGROUND: To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke, following transcatheter aortic valve implantation (TAVI). MATERIALS AND METHODS: Using data from the National Inpatient Sample database for analysis, patients who underwent TAVI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Various preoperative and perioperative risk factors and their association with perioperative strokes were studied. RESULTS: Data on 7566 patients who underwent a TAVI procedure from 2012 to 2013 were extracted. The average age of the patient population was 81.2 ± 0.32 years. The overall perioperative stroke rate in our patient cohort was 2.79%. Majority (94.6%) of the strokes were ischemic. Multivariate analysis showed the following independent risk factors for perioperative strokes after TAVI: female gender odds ratio (OR) = 2.25 (95% confidence interval [CI], 1.42-3.57), higher van Walraven score OR = 6.6 (95% CI = 3.71-11.73), bilateral CS OR = 4.46 (95% CI = 2.03-9.82), and TAVI with a cardiac procedure done under cardiopulmonary bypass OR = 2.84 (95% CI = 1.57-5.14). CONCLUSION: Bilateral carotid disease is a significant risk factor for perioperative strokes following TAVI. Preoperative screening with carotid Doppler to identify high-risk patients appears to be warranted. In addition, patients of female gender were found to have an increased risk for carotid disease.

Cardiac Resynchronization Therapy prevents progression of renal failure in heart failure patients.

BACKGROUND: The goal of this study is to assess the effect of cardiac resynchronization therapy (CRT) over time on renal function and its impact on mortality. The effect of CRT on renal function in patients with heart failure is not well understood. METHODS: All patients who underwent CRT implantation at University of Kansas between year 2000 and 2009 were reviewed and patients who had pre and post CRT renal function studied were included in our study. Stages of chronic kidney disease (CKD) were defined based on Kidney Disease Outcome Quality Initiative (KDOQI) guidelines. The effect of CRT on renal and cardiac function were studied at short term (≤6 months post implantation) and long term (>6 months). RESULTS: A total of 588 patients with mean age of 67 ± 12 yrs were included in the study. CRT responders (defined by increase in LVEF ≥ 5%) were 54% during short term follow-up and 65% on long term follow-up. When compared to baseline, there was no significant deterioration in mean Glomerular Filtration Rate (GFR) during follow up. When analyzed based on the stages of CKD, there was significant improvement of renal function in patients with advanced kidney disease. Multivariate logistic regression analysis showed that stable GFR or an improvement in GFR independently predicted mortality after adjusting for co-morbidities. CONCLUSIONS: CRT was associated with stabilization of renal function in patients with severe LV dysfunction and improvement in stage 4 and 5 CKD. Improved renal function was associated with a lower mortality.

Meta-Analysis of Perioperative Stroke and Mortality in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving safe method with decreasing incidence of perioperative stroke. There is a void in literature concerning the impact of stroke after TAVI in predicting 30-day stroke-related mortality. The primary aim of this meta-analysis was to determine whether perioperative stroke increases risk of stroke-related mortality after TAVI. Online databases, using relevant keywords, and additional related records were searched to retrieve articles involving TAVI and stroke after TAVI. Data were extracted from the finalized studies and analyzed to generate a summary odds ratio (OR) of stroke-related mortality after TAVI. The stroke rate and stroke-related mortality rate in the total patient population were 3.07% (893 of 29,043) and 12.27% (252 of 2,053), respectively. The all-cause mortality rate was 7.07% (2,053 of 29,043). Summary OR of stroke-related mortality after TAVI was estimated to be 6.45 (95% confidence interval 3.90 to 10.66, p <0.0001). Subgroup analyses were performed among age, approach, and valve type. Only 1 subgroup, transapical TAVI, was not significantly associated with stroke-related mortality (OR 1.97, 95% confidence interval, 0.43 to 7.43, p = 0.42). A metaregression was conducted among females, New York Heart Association class III/IV status, previous stroke, valve type, and implantation route. All failed to exhibit any significant associations with the OR. In conclusion, perioperative strokes after TAVI are associated with >6 times greater risk of 30-day stroke-related mortality. Transapical TAVI is not associated with increased stroke-related mortality in patients who suffer from perioperative stroke. Preventative measures need to be taken to alleviate the elevated rates of stroke after TAVI and subsequent direct mortality.

Adult Bone Marrow Cell Therapy for Ischemic Heart Disease: Evidence and Insights From Randomized Controlled Trials.

RATIONALE: Notwithstanding the uncertainties about the outcomes of bone marrow cell (BMC) therapy for heart repair, further insights are critically needed to improve this promising approach. OBJECTIVE: To delineate the true effect of BMC therapy for cardiac repair and gain insights for future trials through systematic review and meta-analysis of data from eligible randomized controlled trials. METHODS AND RESULTS: Database searches through August 2014 identified 48 eligible randomized controlled trials (enrolling 2602 patients). Weighted mean differences for changes in left ventricular (LV) ejection fraction, infarct size, LV end-systolic volume, and LV end-diastolic volume were analyzed with random-effects meta-analysis. Compared with standard therapy, BMC transplantation improved LV ejection fraction (2.92%; 95% confidence interval, 1.91-3.92; P<0.00001), reduced infarct size (-2.25%; 95% confidence interval, -3.55 to -0.95; P=0.0007) and LV end-systolic volume (-6.37 mL; 95% confidence interval, -8.95 to -3.80; P<0.00001), and tended to reduce LV end-diastolic volume (-2.26 mL; 95% confidence interval, -4.59 to 0.07; P=0.06). Similar effects were noted when data were analyzed after excluding studies with discrepancies in reporting of outcomes. The benefits also persisted when cardiac catheterization was performed in control patients as well. Although imaging modalities partly influenced the outcomes, LV ejection fraction improved in BMC-treated patients when assessed by magnetic resonance imaging. Early (<48 hours) BMC injection after myocardial Infarction was more effective in reducing infarct size, whereas BMC injection between 3 and 10 days proved superior toward improving systolic function. A minimum of 50 million BMCs seemed to be necessary, with limited additional benefits seen with increasing cell numbers. BMC therapy was safe and improved clinical outcomes, including all-cause mortality, recurrent myocardial Infarction, ventricular arrhythmia, and cerebrovascular accident during follow-up, albeit with differences between acute myocardial Infarction and chronic ischemic heart disease subgroups. CONCLUSIONS: Transplantation of adult BMCs improves LV ejection fraction, reduces infarct size, and ameliorates remodeling in patients with ischemic heart disease. These effects are upheld in the analyses of studies using magnetic resonance imaging and also after excluding studies with discrepant reporting of outcomes. BMC transplantation may also reduce the incidence of death, recurrent myocardial Infarction, ventricular arrhythmia, and cerebrovascular accident during follow-up.

Disparities in lipid control and statin drug use among diabetics with noncoronary atherosclerotic vascular disease vs those with coronary artery disease.

BACKGROUND: Diabetes mellitus (DM), coronary artery disease (CAD), and noncoronary atherosclerotic vascular diseases (NCVDs) have similar risks of cardiovascular events and similar recommendations for lipid control. There are limited data regarding lipid control in diabetic patients with NCVD in current clinical practice. OBJECTIVE: To assess current day practice of lipid control in patients with DM with NCVD vs those with CAD. METHODS: We retrospectively identified 3336 patients with DM and known atherosclerotic vascular disease between January 2009 and March 2012. We compared demographic variables, lipid levels, and statin use in diabetics with CAD alone vs diabetics without CAD but with one or more NCVD. RESULTS: There were 234 patients in DM with NCVD group and 3102 patients in DM with CAD group. The DM with NCVD group had a higher mean total cholesterol (152 ± 40 vs 146 ± 42 mg/dL; P = .019) and mean low-density lipoprotein (LDL; 86 ± 35 vs 80 ± 34 mg/dL; P = .04) with only 70% of patients achieving LDL of <100 mg/dL (compared with 80% in the DM with CAD group; P < .001). Statin use was 100% in CAD vs 75% in NCVD group (P < .001). In addition to limited use of more potent statins in the NCVD group, there was also a significantly lower dose of statins used overall. CONCLUSION: Our study demonstrates lower use and less aggressive application of statins among diabetics with NCVD compared with diabetics with CAD, resulting in higher mean LDL and total cholesterol in the NCVD group.

Comparison of accuracy of two different methods to determine ankle-brachial index to predict peripheral arterial disease severity confirmed by angiography.

Ankle-brachial index (ABI) is conventionally derived as the ratio of higher of the 2 systolic ankle blood pressures to the higher brachial pressure (HABI method). Alternatively, ABI may be derived using the lower of the 2 systolic ankle pressures (LABI method). The objective of this study was to assess the utility and difference between 2 techniques in predicting peripheral artery disease (PAD). Participants who underwent both ABI measurement and arteriography from July 2005 to June 2010 were reviewed. Angiographic disease burden was scored semiquantitatively (0=<50%, 1=50% to 75%, and 2=>75% stenosis of any lower extremity arterial segment), and PAD by angiography was defined as >50% stenosis of any 1 lower extremity arterial segment. A combined PAD disease score was calculated for each leg. A total of 130 patients were enrolled (260 limbs). The ABI was <0.9 (abnormal) in 68% of patients by HABI method and in 84% by LABI. LABI method had higher sensitivity and overall accuracy to detect PAD compared with the HABI method. Regression analysis showed that an abnormal ABI detected by LABI method is more likely to predict angiographic PAD and total PAD burden compared with HABI. Moreover, abnormal ABI by LABI method had higher sensitivity and accuracy to detect PAD in patients with diabetes and below knee PAD compared with the HABI method. In conclusion, ABI determined by the LABI method has higher sensitivity and is a better predictor of PAD compared with the conventional (HABI) method.

Comparison of lipid management in patients with coronary versus peripheral arterial disease.

Peripheral arterial disease (PAD), similar to coronary artery disease (CAD), is a significant predictor of cardiovascular morbidity and mortality. Guidelines recommend a low-density lipoprotein (LDL) goal of <100 mg/dl for both groups. We assessed whether lipid control and statin use were as aggressively applied to PAD as to patients with CAD. This retrospective study of patients with the diagnosis of CAD, PAD, or both CAD and PAD compared lipid levels and statin use. For comparison of statins, we used a statin potency unit (1 potency unit=10 mg of simvastatin). Among 11,134 subjects (CAD 9,563, PAD 596, and both CAD and PAD 975), mean LDL in the PAD group was higher than the CAD (92 vs 83 mg/dl, respectively, p<0.001) and the combined CAD and PAD groups (92 vs 80 mg/dl, respectively, p<0.001). Fewer patients with PAD achieved a target LDL of <100 mg/dl compared with CAD (62% vs 78%, respectively, p<0.001) and the combined group (62% vs 79%, respectively, p<0.001). Similar differences were noted for a target LDL of <70 mg/dl. Compared with the CAD group, a lesser number of patients with PAD received statin therapy (76% vs 100%, respectively, p<0.001) with lower mean potency unit (5.3 vs 8.1, respectively, p<0.001). In conclusion, our study demonstrated lower use and less aggressive application of statins in patients with PAD compared with patients with CAD, ensuing lower mean LDL in the CAD and combined PAD and CAD groups. Our study suggests that physicians are more aggressive with lipid control in patients with CAD compared with patients with PAD alone.

Clinical trials of cardiac repair with adult bone marrow- derived cells.

The past decade has witnessed a marked increase in the number of clinical trials of cardiac repair with adult bone marrow cells (BMCs). These trials included patients with acute myocardial infarction (MI) as well as chronic ischemic heart disease (IHD) and utilized different types of BMCs with variable numbers, routes of administration, and timings after MI. Given these differences in methods, the outcomes from these trials have been often disparate and controversial. However, analysis of pooled data suggests that BMC injection enhances left ventricular function, reduces infarct scar size, and improves remodeling in patients with acute MI as well as chronic IHD. BMC therapy also improves clinical outcomes during follow-up without any increase in adverse effects. Although the underlying mechanisms of heart repair are difficult to elucidate in human studies, valuable insights may be gleaned from subgroup analysis of key variables. This information may be utilized to design future randomized controlled trials to carefully determine the long-term safety and benefits of BMC therapy.

No consistent evidence of differential cardiovascular risk amongst proton-pump inhibitors when used with clopidogrel: meta-analysis.

BACKGROUND: Data from pharmacokinetic and pharmacodynamic studies indicate that the adverse clopidogrel-proton pump inhibitor (PPI) interaction may vary between PPIs, with pantoprazole considered relatively less problematic. We aimed to evaluate systematically whether individual PPIs differ in their risk for cardiovascular events when concomitantly administered with clopidogrel. METHODS: We searched MEDLINE, EMBASE and Cochrane Trials Register up to December 2011 for randomized and non-randomized studies that reported adverse cardiovascular events with exposure to specific PPIs in patients receiving clopidogrel. We performed random effects meta-analysis, and assessed heterogeneity using the I(2) statistic. RESULTS: A total of 23 studies with 222,311 participants were included. Meta-analysis of major adverse cardiovascular events was mostly limited by moderate-substantial heterogeneity. Pooled estimates of cardiovascular risk were significantly elevated for individual PPIs such as omeprazole, esomeprazole, lansoprazole, and pantoprazole when used with clopidogrel. However, meta-analysis of adverse cardiovascular risk in seven observational studies reporting on PPI therapy alone (without concomitant clopidogrel) also found an elevated odds ratio of 1.28 (95% CI 1.14-1.44) compared with no clopidogrel/no PPI exposure. Meta-analysis of two randomized controlled trials did not show significant adverse cardiovascular effect from omeprazole or esomeprazole. CONCLUSIONS: The absence of consistent evidence on differential cardiovascular risk amongst PPIs (particularly regarding safety of pantoprazole) is in direct opposition to the platelet function and pharmacokinetic data. Our findings of increased cardiovascular risk with PPIs in the absence of clopidogrel suggest that confounding and bias are strong possibilities. The clinical validity or relevance of the hypothesized PPI-clopidogrel interaction remains questionable.

Adult bone marrow cell therapy improves survival and induces long-term improvement in cardiac parameters: a systematic review and meta-analysis.

BACKGROUND: Despite rapid clinical translation and widespread enthusiasm, the therapeutic benefits of adult bone marrow cell (BMC) transplantation in patients with ischemic heart disease continue to remain controversial. A synthesis of the available data is critical to appreciate and underscore the true impact of this promising approach. METHODS AND RESULTS: A total of 50 studies (enrolling 2625 patients) identified by database searches through January 2012 were included. Weighted mean differences for changes in left ventricular (LV) ejection fraction, infarct size, LV end-systolic volume, and LV end-diastolic volume were estimated with random-effects meta-analysis. Compared with control subjects, BMC-treated patients exhibited greater LV ejection fraction (3.96%; 95% confidence interval, 2.90-5.02; P<0.00001) and smaller infarct size (-4.03%, 95% confidence interval, -5.47 to -2.59; P<0.00001), LV end-systolic volume (-8.91 mL; 95% confidence interval, -11.57 to -6.25; P<0.00001), and LV end-diastolic volume (-5.23 mL; 95% confidence interval, -7.60 to -2.86; P<0.0001). These benefits were noted regardless of the study design (randomized controlled study versus cohort study) and the type of ischemic heart disease (acute myocardial infarction versus chronic ischemic heart disease) and persisted during long-term follow-up. Importantly, all-cause mortality, cardiac mortality, and the incidence of recurrent myocardial infarction and stent thrombosis were significantly lower in BMC-treated patients compared with control subjects. CONCLUSIONS: Transplantation of adult BMCs improves LV function, infarct size, and remodeling in patients with ischemic heart disease compared with standard therapy, and these benefits persist during long-term follow-up. BMC transplantation also reduces the incidence of death, recurrent myocardial infarction, and stent thrombosis in patients with ischemic heart disease.

Aging reduces left atrial performance during adrenergic stress in middle aged and older patients.

BACKGROUND: During adrenergic stress, the influence of age on left atrial (LA) function is unknown. We hypothesized that aging decreases LA total emptying fraction (LAEF) during maximal adrenergic stress. The aim of the study was to determine the influence of aging on LA function during adrenergic stress in middle aged and older patients. METHODS: We enrolled 167 middle aged and elderly participants, and measured LA and left ventricular (LV) volumes using a multi-slice three-dimensional cine white blood cardiovascular magnetic resonance (CMR) technique before and during intravenous dobutamine infused to achieve 80% of the maximum heart rate response for age. Paired sample t-test was used to detect differences in LA and LV volumes between baseline and peak dose stage of dobutamine stress CMR, and multivariable linear regression was used to identify predictors of LA function. RESULTS: Participants averaged 68 ± 8 years in age, 53% were men, 25% exhibited coronary artery disease, 35% had diabetes, 9% had a remote history of atrial fibrillation, 90% had hypertension, and 11% had inducible LV wall motion abnormalities indicative of ischemia during dobutamine CMR. Increasing age correlated with LA volumes (maximal and minimal) and inversely correlated with LAEF at rest and after peak adrenergic stress. Age was an independent predictor of LAEF during adrenergic stress, even after accounting for gender, LV volumes, and other co-morbidities including inducible ischemia. CONCLUSIONS: Age is associated with a decrease in LA function during adrenergic stress even after adjusting for co-morbidities associated with cardiovascular disease and LV function.

Meta-analysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation.

The effects of radiofrequency catheter ablation (RFCA) on left atrial (LA) size, volumes, and function in patients with atrial fibrillation (AF) are not well understood. The aim of this study was to systematically review the effects of RFCA on LA size, volumes, and function in patients with AF. Medline, the Web of Science, the Cochrane Central Register of Controlled Trials, and the reference lists of retrieved reports were searched for relevant studies through April 2009. Studies conducted in patients with AF were included if their primary outcomes were changes in LA size or volumes and/or function before and after RFCA. Weighted mean differences for changes in LA diameter, LA maximum volume, LA minimum volume, LA ejection fraction, and LA active emptying fraction were estimated using fixed- and random-effects meta-analyses. Seventeen relevant studies (enrolling 869 patients) among 192 identified studies were included in the final analysis. Compared to preablation values, there were significant decreases in LA diameter and LA volumes at postablation follow-up. However, compared to preablation values, there were no significant differences in LA ejection fraction and LA active emptying fraction at postablation follow-up. Decreases in LA diameter and LA volumes remained significant in those without AF recurrence but not in those with AF recurrence. LA ejection fraction and LA active emptying fraction did not decrease in patients without AF recurrence, whereas they decreased in patients with AF recurrence. In conclusion, successful RFCA in patients with AF significantly decreases LA size and volumes and does not seem to adversely affect LA function.

Predictors of coronary artery disease in patients with left bundle branch block who undergo myocardial perfusion imaging.

BACKGROUND: Due to difficulties in diagnosing coronary ischemia in patients with left bundle branch block (LBBB), identifying clinical characteristics that might help to predict coronary artery disease (CAD) is important. Our study aimed to identify clinical predictors of CAD among patients with and without LBBB who undergo myocardial perfusion imaging (MPI). METHODS: All patients with LBBB who underwent MPI (LBBB group) from June 2005 to February 2007 were compared with patients with normal baseline electrocardiography who underwent treadmill MPI (non-LBBB group) during the same period. RESULTS: LBBB patients with CAD were younger and had lower ejection fraction (EF) compared to LBBB patients without CAD. Similarly non-LBBB patients with CAD had lower EF, but did not differ significantly in age compared to non-LBBB patients without CAD. Regression analysis among patients with LBBB showed that EF < 55% was the most significant predictor of CAD, after controlling for other factors. A regression analysis in non-LBBB patients showed that male gender and EF pound 55% were significant predictors of CAD. A regression analysis conducted in the combined data of both LBBB and non-LBBB groups showed male gender, EF pound 55% and LBBB to be the most significant predictors of CAD. CONCLUSIONS: Patients with LBBB have a high probability of CAD based on MPI findings. Patients with LBBB and reduced EF have a much higher likelihood of CAD compared to patients without LBBB and normal EF. Further studies on early invasive approach in patients with LBBB and reduced EF seem warranted.