Budget Impact Analysis of Impella CP® Utilization in the Management of Cardiogenic Shock in France: A Health Economic Analysis.

INTRODUCTION: Early detection and treatment of cardiogenic shock (CS) is crucial to avoid irreparable multiorgan damage and mortality. Impella CP® is a novel temporary mechanical circulatory support (MCS) device associated with greater hemodynamic support and significantly fewer device-related complications compared with other MCS devices, e.g., intra-aortic balloon pumps (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study evaluated the budget impact of introducing Impella CP versus IABP and VA-ECMO in patients with CS following an acute myocardial infarction (MI) in France. METHODS: A budget impact model was developed to compare the cost of introducing Impella CP with continuing IABP and VA-ECMO treatment from a Mandatory Health Insurance (MHI) perspective in France over a 5-year time horizon, with 700 patients with refractory CS assumed to be eligible for treatment per year. Costs associated with Impella CP and device-related complications for all interventions were captured and clinical input data were based on published sources. Scenario analyses were performed around key parameters. RESULTS: Introducing Impella CP was associated with cumulative cost savings of EUR 2.7 million over 5 years, versus continuing current clinical practice with IABP and VA-ECMO. Cost savings were achieved in every year of the analysis and driven by the lower incidence of device-related complications with Impella CP, with estimated 5-year cost savings of EUR 22.4 million due to avoidance of complications. Total cost savings of more than EUR 250,000 were projected in the first year of the analysis, which increased as the market share of Impella CP was increased. Scenario analyses indicated that the findings of the analysis were robust. CONCLUSION: Treatment with Impella CP in adult patients aged less than 75 years in a state of refractory CS following an MI was projected to lead to substantial cost savings from an MHI perspective in France, compared with continuing current clinical practice.

Budget Impact Associated with the Introduction of the Impella 5.0® Mechanical Circulatory Support Device for Cardiogenic Shock in France.

AIM: Cardiogenic shock (CS), if not diagnosed and treated rapidly, can lead to irreversible multiorgan damage and death. An economic analysis was conducted to determine the budget impact of the introduction of Impella 5.0®, a mechanical circulatory support (MCS) device that directly unloads the left ventricle, into clinical practice in patients with left ventricular CS in France. METHODS: A budget impact model was developed to compare the cost of Impella 5.0 with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) from the perspective of the French national healthcare insurer. Costs associated with Impella 5.0, plus complication-related costs for VA-ECMO or Impella 5.0 from 2019 were included and clinical input data relating to complication rates and time spent on device were sourced from published literature. Extensive scenario and one-way deterministic sensitivity analyses were performed to explore the influence of uncertainty around key input parameters. RESULTS: Over a time horizon of 5 years, the introduction of Impella 5.0 was associated with cumulative savings of EUR 4.3 million. The results were driven by the lower risk of device-related complications associated with Impella 5.0. Savings were apparent from Year 1 onwards, with savings in excess of EUR 375,000 projected in Year 1 alone. On a per-patient level, in Year 1, estimated savings with the introduction of Impella 5.0 totaled EUR 616 per patient. Sensitivity analyses showed that the findings of the analysis were robust. CONCLUSION: The Impella 5.0 device was associated with cumulative cost savings in excess of EUR 4 million over a 5-year period compared with current practice. Projected savings were driven by a lower rate of device-related complications with Impella 5.0 compared with VA-ECMO.

Which echocardiographic parameters improve the risk prediction for peri-operative outcomes in patients undergoing coronary bypass surgery: a prospective study.

OBJECTIVE: To assess the performance of transthoracic echocardiographic parameters to predict operative mortality and morbidity in patients undergoing coronary artery bypass grafting, and to assess its incremental prognostic value as compared to the Society of Thoracic Surgeons (STS) score. MATERIALS AND METHODS: We prospectively collected the clinical and biological data required to calculate the STS score in patients hospitalised for coronary artery bypass grafting. Preoperative transthoracic echocardiography was performed for each patient. The primary endpoint was 30-day mortality or major morbidity (i.e. stroke, renal failure, prolonged ventilation, deep sternal wound infection, reoperation) as defined by the STS. The secondary endpoint was prolonged hospitalisation for over 14 days. RESULTS: A total of 172 patients was included (mean age 66.1±10.2 years, 12.2% were women). The primary endpoint occurred in 33 patients (19.2%), and 28 patients (16.3%) had a prolonged hospital stay. Independent predictive factors for the primary endpoint were an increased left atrial volume (>31 mL/m²; odds ratio (OR) 3.55, 95% confidence interval (CI) 1.38-9.12; P=0.004) and a decreased tricuspid annular plane systolic excursion (<20 mm; OR 3.45, 95% CI 1.47-8.21; P=0.008). The predictive value of the multivariate model increased when the two echocardiographic parameters were added to the STS score (area under the curve 0.598 vs. 0.695, P=0.001; integrated discrimination improvement 7.44%). CONCLUSION: In patients undergoing coronary artery bypass grafting, preoperative assessment of left atrial size and tricuspid annular plane systolic excursion should be performed systematically, as it provides additional prognostic information to the STS score.

Echocardiography is useful to predict postoperative atrial fibrillation in patients undergoing isolated coronary bypass surgery: A prospective study.

OBJECTIVE:: Postoperative atrial fibrillation is a major complication following coronary artery bypass graft. We hypothesized that, beyond clinical and electrocardiogram (ECG) data, transthoracic echocardiography could improve the prediction of postoperative atrial fibrillation. METHODS:: We prospectively studied 169 patients in sinus rhythm who underwent isolated coronary artery bypass graft in our institution. Clinical, biological, ECG and transthoracic echocardiography data were collected within 24 h before surgery. The patients were continuously monitored during the first five days, and then had daily 12-lead ECG afterwards until discharge. Postoperative atrial fibrillation was defined by any episode >10 min. RESULTS:: Postoperative atrial fibrillation was found in 65 patients (38%). Compared with those without, patients with postoperative atrial fibrillation were significantly older ( p=0.008), had more frequently a history of hypertension ( p=0.009), history of atrial fibrillation ( p<0.001) and New York Heart Association class ⩾III ( p=0.004). They also had longer PR interval ( p=0.005), higher preoperative NT-pro brain natriuretic peptide level ( p=0.006), left ventricle end-diastolic volume ( p=0.002), indexed left ventricle mass ( p<0.0001), indexed maximal left atrial volume ( p<0.0001), maximal right atrial area ( p<0.001) and lower left ventricle ejection fraction ( p=0.04). In multivariate analysis, history of atrial fibrillation (odds ratio =6.1, 95% confidence interval: 1.4-26.0, p=0.02) and indexed maximal left atrial volume (odds ratio =1.13, 95% confidence interval: 1.1-1.2, p=0.001) were the only two independent predictive factors of postoperative atrial fibrillation. The addition of echocardiographic parameters improved the predictive value (χ2) of the model, from 34 to 57. CONCLUSION:: A history of atrial fibrillation and indexed left atrial maximal volume are the best predictors of the occurrence of postoperative atrial fibrillation following coronary artery bypass graft. The identification of high risk population of postoperative atrial fibrillation using these two factors could lead to the development of targeted strategies to limit this frequent complication in these patients.

The intrinsic prognostic value of the ankle-brachial index is independent from its mode of calculation.

The object of this study was to compare the prognostic value of different methods of ankle-brachial index (ABI) calculation. From April 1998 to September 2008, we calculated the ABI in 1223 patients before coronary artery bypass grafting. The ABI was calculated according to five different calculation modes of the numerator. The patients were classified into three groups: clinical peripheral artery disease (PAD), subclinical PAD if no clinical history but abnormal ABI (< 0.90 or > 1.40), and no PAD. The primary outcome was total mortality. During a follow-up of 7.6 years (0.1-15.9), 406 patients (33%) died. The prevalence of the subclinical PAD varied from 22% to 29% according to the different modes of ABI calculation. Areas under the ROC curve to predict mortality according to different calculation modes varied from 0.608 ± 0.020 to 0.625 ± 0.020 without significant differences. The optimal ABI threshold to predict mortality varied for every method, ranging from 0.87 to 0.95. In multivariate models, ABI was significantly and independently associated with total mortality (hazard ratio (HR) = 1.46, 95% CI: 1.15-1.85, p = 0.002); however, this association was not significantly different between the various methods (HRs varying from 1.46 to 1.67). The use of the optimal ABI threshold for each calculation mode (rather than standard 0.90) allowed a slight improvement of the model. In conclusion, the ABI prognostic value to predict mortality is independent from its method of calculation. The use of different optimal thresholds for each method enables a comparable prognosis value.

Mid- and long-term prognosis of off- vs. on-pump coronary artery bypass graft in patients with multisite artery disease.

BACKGROUND: Among patients with coronary artery disease (CAD), around 25% have multisite artery disease (MSAD). Patients with CAD and MSAD are at higher risk of peri-operative and long-term cardiovascular events. Whether off-pump coronary bypass grafting (CABG) can improve their prognosis is unknown. We aimed to assess the benefits of off- vs. on-pump cardiac surgery in patients undergoing CABG, according to coexistence of extra-cardiac artery disease. METHODS: Between April 1998 and September 2008, 1221 patients undergoing CABG without any other intervention were enrolled. Overall death and major cardiovascular events were recorded at 1-month and during long-term follow-up. A propensity score (PS), derived from all relevant variables (P<0.25) associated with on-pump as compared to off-pump CABG, and representing the likelihood for each individual patient to receive off-pump CABG, was calculated. RESULTS: MSAD was observed in 279 patients (23%). Off-pump CABG was performed in 208 (17%) patients. The median follow-up was 7.6 years. The 10-year mortality was significantly lower in off- vs. on-pump CABG group (74±4% vs. 68±2%, P=0.024). In patients with MSAD, there was a trend for better survival for off- vs. on-pump CABG (63±8% vs. 50±4%, P=0.078). After adjustment for PS, we found no further difference between on- and off-pump CABG both in the whole cohort (HR=1.30, P=0.10), as well as in MSAD patients (HR=1.51, P=0.14). CONCLUSIONS: Patients with MSAD receiving CABG are at worst prognostic than those with isolated CAD. In these patients, we found no significant difference in the long-term mortality and cardiovascular events between on- and off-pump CABG.

Adult Bone Marrow Three-Dimensional Phenotypic Landscape of B-Cell Differentiation.

BACKGROUND: The different B-cell subsets in human bone marrow result from a dynamic equilibrium between endogenous production, B-cell bone marrow reentry and terminal plasma cell differentiation. Our aim was to define and quantify the different medullary B-cell subsets. METHODS: A series of 32 normal adult bone marrows plus 15 normal adult blood samples was studied by nine color flow cytometry (CD10, CD19, CD24, CD27, CD34, CD38, CD45, IgM, and IgD). With the Kaluza software radar plots, two 2D triple parametric histograms (CD10/CD34/CD45 and CD27/IgM/IgD) were set-up to identify six progenitor and five mature B-cell subsets. RESULTS: Very early B-cell progenitors were CD19neg/CD10pos/CD34pos. B-cell progenitors were split into five subsets on the CD10/CD34/CD45 triple parametric histogram, sequentially ordered according to the loss of CD34 and CD10 and acquisition of surface IgM and IgD. CD19pos/CD38low mature B-cells were divided into four subsets on the CD27/IgM/IgD triple parametric histogram, with two stages of naïve B-cells and two CD27hi marginal zone and switched memory B-cell compartments. CD19pos/CD34neg/CD10low immature B-cells were the main bone marrow B-cell subset, accounting for one third of bone marrow B-cells. Transitional B-cells were the only immature bone marrow stage found in the blood. Compared to blood, the bone marrow was enriched in both marginal zone and switched B-cells. CONCLUSION: We provide the first analysis of 3D B-cell differentiation by multicolor flow cytometry leading to propose reference values for each bone marrow and blood B-cell compartment. This warrants further exploration of normal and pathological human B-cell maturation. © 2018 International Clinical Cytometry Society.

Fulminant giant-cell myocarditis on mechanical circulatory support: Management and outcomes of a French multicentre cohort.

AIMS: Giant-cell myocarditis (GCM) is a rare and often fatal form of myocarditis. Only a few reports have focused on fulminant forms. We describe the clinical characteristics, management and outcomes of GCM patients rescued by mechanical circulatory support (MCS). METHODS AND RESULTS: The clinical features, diagnoses, treatments and outcomes of MCS-treated patients in refractory cardiogenic shock secondary to fulminant GCM admitted to eight French intensive care units (2002-2016) were analysed. We also conducted a systematic review of this topic. Thirteen patients (median age 44 [range 21-76]years, Simplified Acute Physiology Score II 55 [40-79]) in severe cardiogenic shock (median [range] left ventricular ejection fraction 15% [15-35%] and blood lactate 4 mmol/L) were placed on MCS 4 [0-28]days after hospital admission. Severe arrhythmic disturbances were frequent (77%), with six (46%) patients experiencing an electrical storm prior to MCS. Venoarterial extracorporeal membrane oxygenation was the first MCS option for 11 (85%) patients. GCM was diagnosed in five (38%) patients before transplant or death and treated with immunosuppressants; infections were the main complication (80%). Four patients died on MCS and no patient presented long-term survival free from heart transplant (nine patients, 69%). All transplanted patients were alive 1year later and no GCM recurrence was reported after median follow-up of 42 [12-145]months. CONCLUSION: Outcomes of fulminant GCMs may differ from those of milder forms. In this context, heart transplant might likely be the only long-term survival option.

Relation Between Renin-Angiotensin System Blockers and Survival Following Isolated Aortic Valve Replacement for Aortic Stenosis.

Renin-angiotensin system blockers (RASb) improve cardiac remodeling, but their clinical utility after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) is unclear. We aimed to assess the impact of RASb on short- and long-term survival following isolated SAVR for severe AS. From January 2005 to January 2014, 508 consecutive patients had isolated SAVR for severe AS. Patients with RASb (n = 286; 53%) were more often female (p = 0.039), hypertensive (p < 0.0001), and diabetic (p = 0.004), with higher body mass index (p < 0.0001) and EuroSCORE II (p = 0.025), and lower mean aortic pressure gradient (p = 0.011). The 30-day mortality was similar in both groups (RASb: 3% vs no RASb: 5.8%, p = 0.13), but lower under angiotensin receptor blockers (ARB) than angiotensin-converting enzyme inhibitors (ACEi; 0.7% vs 5.6%, p = 0.017). Patients under RASb had a better 8-year survival than those without RASb (83 ± 3% vs 52 ± 5%, p < 0.0001), confirmed in a propensity score-matched pairs analysis (82 ± 4% vs 50 ± 7%, p < 0.0001). Regarding different types of RASb, patients under ARB had lower mortality than those under ACEi (87 ± 3% vs 79 ± 4%, p = 0.028). In multivariate analysis, the use of RASb was associated with improved survival (hazard ratio = 0.31, 95% confidence interval 0.20 to 0.47, p < 0.0001), with lower mortality under ARB than under ACEi (hazard ratio = 0.39, 95% confidence interval 0.18 to 0.85, p = 0.018). In this observational study, the use of RASb was associated with improved long-term outcome after isolated SAVR for severe AS. A randomized clinical trial is mandatory.

Usefulness of Electrocardiographic Strain to Predict Survival After Surgical Aortic Valve Replacement for Aortic Stenosis.

Electrocardiographic (ECG) strain has been reported as a specific marker of midwall left ventricular (LV) myocardial fibrosis, predictive of adverse clinical outcomes in aortic stenosis (AS), but its prognostic impact after aortic valve replacement (AVR) is unknown. We aimed to assess the impact of ECG strain on long-term mortality after surgical AVR for AS. From January 2005 to January 2014, patients with interpretable preoperative ECG who underwent isolated AVR for AS were included. ECG strain was defined as ≥1-mm concave downslopping ST-segment depression with asymmetrical T-wave inversion in lateral leads. Mortality was assessed over a follow-up period of 4.8 ± 2.7 years. Among the 390 patients included, 110 had ECG strain (28%). They had significantly lower body mass index, higher mean transaortic pressure gradient and Cornell-product ECG LV hypertrophy than in those without ECG strain. There was also a trend for lower LV ejection fraction in patients with ECG strain as compared with those without. Patients with ECG strain had significantly lower 8-year survival than those without. ECG strain remained associated with reduced survival both in patients with and without LV hypertrophy (p <0.0001 for both). After adjustment, ECG strain remained a strong and independent determinant of long-term survival (hazard ratio 4.4, p <0.0001). Similar results were found in patients with LV hypertrophy or without LV hypertrophy. In the multivariate model, the addition of ECG strain provided incremental prognostic value (p <0.0001). In conclusion, in patients with AS, ECG strain is associated with 4-fold increased risk of long-term mortality after isolated AVR, regardless of preoperative LV hypertrophy.

Outcomes after surgery for acute type A aortic dissection in "non-Marfan syndrome" patients with long life expectancy: A 24-year follow-up.

BACKGROUND: Long-term survival and risk of reoperation in "non-Marfan syndrome" patients with a long life expectancy who undergo emergency surgery for acute type A aortic dissection (aTAAD) are not well known. AIM: To analyse survival, risk of reoperation and quality of life in this population. METHODS: From 1990 to 2010, all patients aged≤50 years and not affected by Marfan syndrome, who underwent emergency surgery for aTAAD at two institutions, were included in this analysis. Patients were categorized into four groups according to the extension of the aortic replacement: SUPRACORONARY, ROOT, ARCH and EXTENSIVE. RESULTS: Sixty-six patients (mean age 45±4 years; range 34-50 years) were considered eligible for this analysis. Overall in-hospital mortality was 24% (16/66 patients); and 25%, 23%, 20.5% and 43% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Mean follow-up among survivors was 10.5±7.2 years (range: 0.1-24.7 years). Overall 10-year survival was 55±6%; and 75±12%, 69±13%, 47±8% and 28±17% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. Overall freedom from reoperation on the aorta was 73±7.5%; and 40±20%, 75±21%, 78±8% and 100% in the SUPRACORONARY, ROOT, ARCH and EXTENSIVE groups, respectively. CONCLUSIONS: In our experience, patients who underwent isolated supracoronary ascending aorta or root replacement showed the most satisfactory late survival. However, because the risk of reoperation is low when the replacement is extended to the root, our data suggest that root replacement could represent a good compromise between operative mortality and long-term survival.

Fate of aortic bioprostheses: An 18-year experience.

OBJECTIVE: To report our experience in aortic valve replacement with the Mitroflow (Sorin, Vancouver, Canada) aortic bioprosthesis. METHODS: We retrospectively reviewed all patients who underwent aortic valve replacement with a Mitroflow bioprosthesis at our institution from January 1994 to December 2011. No exclusion criteria were retained. Patients were followed yearly. Echocardiography follow-up was performed systematically before the hospital discharge and annually by patients' cardiologists. RESULTS: Seven hundred twenty-eight patients (mean age, 76 ± 6 years; range, 33-91 years) underwent aortic valve replacement with Mitroflow 12A or LX model and were included in this analysis. 30-day mortality for nonemergent isolated aortic valve replacement was 5.5%. Eight patients (1%) underwent reoperation for structural valve deterioration (SVD) and 30 patients (5.8%) presented echocardiographic signs of SVD. Actuarial freedom from reoperation for SVD was 99% ± 0.5% and 95% ± 5% at 10 and 15 years. Actuarial freedom from echocardiographic signs of SVD was 77% ± 5% and 56% ± 11% at 10 and 15 years, respectively. At the univariate analysis, only the mean gradient at discharge (P = .0200), the prevalence of size 19 (P = .0273), and severe patient-prosthesis mismatch (P = .0384) were significantly different in patients developing SVD at follow-up. Freedom from echocardiographic signs of SVD at 8 years were 88% ± 4% and 64% ± 13% in patients with a Mitroflow > 19 and Mitroflow 19, respectively (log-rank test, P = .0056; Wilcoxon test, P = .0589). CONCLUSIONS: Overall outcomes were satisfactory. However the risk of early SVD seems higher for the Mitroflow size 19. This size should be reserved for applications when annulus enlargement is risky or there is an anatomic contraindication to sutureless or stentless valve.

Octogenarians with uncomplicated acute type a aortic dissection benefit from emergency operation.

BACKGROUND: The management of acute type A aortic dissection (aTAAD) in octogenarian patients is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS: Beginning in January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 79 consecutive patients enrolled up to December 2010. Their median age was 81.6 years (range, 80 to 89 years). Sixteen patients (20%) presented a complicated type because of a neurologic deficit, mesenteric ischemia, a requirement for cardiopulmonary resuscitation, or some combination of those features. Operations followed the standard procedure recommended for younger patients. Follow-up was 95% complete (mean, 4.6±2.8 years). RESULTS: The overall in-hospital mortality was 44.3%. The in-hospital mortality among patients with uncomplicated aTAAD was 33.3%. Multivariate analysis identified complicated aTAAD as the only risk factors for in-hospital mortality (p<0.0001). Postoperative complications occurred in 50 patients (68.5%) and were associated with a higher mortality (p<0.0001). The overall survival was 53% at 1 year and 32% at 5 years. In uncomplicated aTAAD, the overall survival was 63% at 1 year and 38% at 5 years. CONCLUSIONS: Octogenarians with uncomplicated aTAAD benefit from emergency surgical repair. In those patients, early and midterm outcomes are good and are similar to those in published series of younger patients. Complicated aTAAD should be medically managed.

Results of mechanical circulatory support in France.

OBJECTIVE: To present the analyzed results on mechanical circulatory support (MCS) collected over a 7-year period, from 2000 to 2006, in France. METHODS: A cohort of 520 patients was analyzed. Mean age was 43.7 ± 13.6 years. The main causes of cardiac failure were ischemic cardiomyopathy (39%), idiopathic dilated cardiomyopathy (41.3%), or myocarditis (6.4%). Bridge to transplantation was indicated in 87.8% of patients, bridge to recovery in 9%, while destination therapy was proposed in 3.2% of patients. RESULTS: For patients in cardiogenic shock or advanced heart failure undergoing device implantation as bridge to transplantation or recovery (n=458), overall mortality was 39% (n=179). The main causes of mortality under MCS were multi-organ failure (MOF) (57.4%), neurological events (14.1%), or infections (11.9%). Heart transplantation was performed in 249 (54.3%) patients. The main causes of death following heart transplantation were primary graft failure (22.4%), MOF (14.3%), neurological event (14.3%), or infection (10.2%). Long-term survival in transplanted patients was 75 ± 2.8% at 1 year and 66 ± 3.4% at 5 years. CONCLUSIONS: MCS is an essential therapeutic tool to save the life of young patients with cardiogenic shock or advanced cardiac failure. Early MCS implantation and the availability of a device that is adapted to the patient's clinical status are prerequisites for reducing overall mortality rates.

Usefulness of postoperative heart rate as an independent predictor of mortality after coronary bypass grafting.

Heart rate (HR) predicts mortality and cardiovascular events in the general population and in patients with coronary artery disease. However, little evidence is available for patients after coronary revascularization. The aim of this study was to assess the prognostic value of ambulatory postoperative HR after coronary artery bypass grafting. Data from a prospective cohort study enrolling patients who underwent nonurgent coronary artery bypass grafting from 1998 to 2002 were analyzed. Baseline postoperative HR was measured 2 months after surgery, and patients were followed annually thereafter. The primary outcome was all-cause mortality. The secondary outcome combined any of the following events: death, nonfatal acute coronary syndromes, stroke or transient ischemic attack, secondary coronary revascularization, or vascular surgery. Seven hundred ninety-four patients (mean age 65.8 ± 9.3 years) were eligible for follow-up, predominantly men (84.1%). The mean follow-up duration was 3.2 ± 1.3 years, during which 40 patients (5.0%) died. In the univariate analysis, HR >90 beats/min was significantly associated with all outcomes. After adjustments for major confounding factors and the use of ß blockers, postoperative HR >90 beats/min remained significantly associated with the secondary outcome (hazard ratio 2.26, 95% confidence interval 1.04 to 4.91, p = 0.04). Association of postoperative HR >90 beats/min with all-cause mortality was only borderline in the multivariate analysis (hazard ratio 3.57, 95% confidence interval 0.90 to 14.17, p = 0.07), because of the limited sample population size. In conclusion, postoperative HR >90 beats/min may be associated with poor prognoses in patients with coronary artery disease, even after surgical revascularization.

Comparison of detection of F-18 fluorodeoxyglucose positron emission tomography and 99mTc-hexamethylpropylene amine oxime labelled leukocyte scintigraphy for an aortic graft infection.

To compare F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG-PET) and (99m)Tc-hexamethylpropylene amine oxime ((99m)TC-HMPAO) labelled leukocyte scintigraphy for the diagnosis of vascular graft infection. A thoraco-abdominal CT-angiography and a (99m)TC-HMPAO labelled leukocyte scintigraphy did not show any graft infection in this case report whereas an F-18 FDG-PET showed a metabolic uptake around and all along the vascular graft. Further comparison between these two explorations is needed since the two techniques have not been compared in vascular graft infection.

Inhibition of platelet GPIIb-IIIa and P-selectin expression by aspirin is impaired by stress hyperglycemia.

Increased aspirin resistance may contribute to the increase in thrombotic events observed in patients with type 2 diabetes. In this study, we examined if acute exposure to increased plasma glucose impaired the inhibitory effects of aspirin on platelet activation. Whole-blood samples were incubated with 100 (euglycemia), 200, 300, and 600 mg/dl glucose followed by incubation with aspirin [acetylsalicylic acid (ASA)]. Using flow cytometry, GPIIb-IIIa and P-selectin were analyzed in unstimulated and arachidonic acid (AA)-stimulated platelets. In euglycemic blood, AA caused a significant increase in platelet GPIIb-IIIa expression [unstimulated: 59.5+/-8.2 total fluorescence intensity (TFI), AA stimulated: 319.6+/-42.7 TFI, P=.002] and P-selectin (4.4+/-0.7 and 179.5+/-38.5 TFI, P<.001). In vitro, ASA significantly inhibited both GPIIb-IIIa expression (36.5%) and P-selectin expression (81%; P<.005). However, increased blood glucose (200 mg/dl) significantly impaired the inhibitory effect of ASA (84% for GPIIb-IIIa, P<.005; 48% for P-selectin, P=NS). Increasing glucose to 600 mg/dl completely overwhelmed the inhibitory effect of ASA. A statistically significant interaction between glucose concentration and ASA dose was found (P<.001 for GPIIb-IIIa and P=.004 for P-selectin). In vitro, concentration-dependent stress hyperglycemia significantly impaired the inhibitory effects of aspirin on human platelet GPIIb-IIIa and P-selectin expression. Under acute hyperglycemic conditions, the effectiveness of ASA to inhibit platelets via the AA-activation pathway may be significantly reduced.