One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques.

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Hybrid approach improves success of chronic total occlusion angioplasty.

OBJECTIVES: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques. METHODS: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan (J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. Inhospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded. RESULTS: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions (J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions (J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification ('investment procedures') at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%). CONCLUSIONS: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

Left atrial appendage closure with AMPLATZER cardiac plug for stroke prevention in atrial fibrillation: initial Asia-Pacific experience.

BACKGROUND: Left atrial appendage (LAA) is the main source of left atrial thrombus that causes stroke in patients with non-valvular atrial fibrillation (NVAF). This study reported the initial safety, feasibility, and 1-yr clinical outcomes following AMPLATZER cardiac plug (ACP) implantation in Asia-Pacific region. METHODS: Twenty NVAF patients (16 males, age 68 ± 9 yr) with high risk for developing cardioembolic stroke (CHADS(2) score: 2.3 ± 1.3) and contraindications to warfarin received ACP implants from June 2009 to May 2010. Patients received general anesthesia (n = 9) or controlled propofol sedation (n = 11) and the procedures were guided by fluoroscopy and transesophageal echocardiography (TEE). Clinical follow-up was arranged at 1 month and then every 3 months after implantation, whereas, a TEE was scheduled at 1 month upon completion of dual anti-platelet therapy. RESULTS: The LAA was successfully occluded in 19/20 patients (95%) at two Asian centers. One procedure was abandoned because of catheter-related thrombus formation. Other complications included coronary artery air embolism (n = 1) and TEE-attributed esophageal injury (n = 1). The median procedural and fluoroscopic times were 79 (IQR: 59-100) and 18 (IQR 12-27) minutes, respectively. The mean size of implant was 23.6 ± 3.1 mm. The average hospital stay was 1.8 ± 1.1 days. Follow-up TEE showed all the LAA orifices were sealed without device-related thrombus formation. No stroke or death occurred at a mean follow-up of 12.7 ± 3.1 months. CONCLUSIONS: Our preliminary data suggested LAA closure with ACP is safe, feasible with encouraging 1-yr clinical outcomes. Further large-scaled trials are needed to confirm the efficacy of this device.

Aorto-left atrial fistula post-percutaneous device ASD closure.

Use of percutaneous devices for closure of atrial septal defects (ASD) continues to increase owing to relative safety and ease of implementation compared with traditional surgical repair. Complications such as perforation and displacement requiring surgical intervention have been reported. We describe a case of perforation with intracardiac fistula formation, with an underlying mechanism likely to be similar to the few cases previously described, occurring during medium term follow up after ASD device closure. Appropriate case selection can reduce the incidence of this complication with caution taken in ASD cases with deficient aortic and superior rims.

Left main stem rupture caused by methicillin resistant Staphylococcus aureus infection of left main stent treated by covered stenting.

Coronary artery infection after angioplasty or stent implantation is a rare and dreaded complication of percutaneous coronary intervention. 80% of the cases are due to Staphylococcus aureus. About half the cases lead to rupture or perforation of the coronary artery while the other half presents as abscesses or aneurysms. Surgical treatment is the conventional therapeutic modality but it carries a high mortality. We report a case of a high risk patient who had methicillin resistant Staphylococcus aureus infection of left main stem stent leading to rupture and pseudoaneurysm formation that is successfully treated with stent graft.

The confluent balloon technique--two cases illustrating a novel method to achieve rapid wire crossing of chronic total occlusion during retrograde approach percutaneous coronary intervention.

We describe two cases of a retrograde approach to treat a chronic total occlusion (CTO) of the right coronary artery in which we were initially unable to achieve wire crossing. A novel technique of pushing both antegrade and retrograde balloons into the CTO lesion so that the balloons overlapped each other during inflation created a new confluent subintimal space allowing easy, reliable and rapid passing of the retrograde wire into the antegrade true lumen. This novel "confluent balloon" method is recommended to other operators who may struggle with wire crossing during a retrograde approach to CTOs.

Retrograde chronic total occlusion intervention: tips and tricks.

Retrograde approach via collateral channels in coronary angioplasty for chronic total occlusion (CTO) can improve the success rate. Most interventionists will meet a few cases where the retrograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of proper equipment and expertise. In this article, we give detail description of techniques to shorten the guiding catheter, to traverse the collateral channels, and to cross the CTO. We also illustrate the difficulties in collateral channel crossing with different examples providing a basic guide for case selection purposes. We hope that many others would find rewardingly successful cases of retrograde approach CTO percutaneous coronary intervention, as in our experience.

Three cases of left main stem thrombus complicating PCI: the role of FilterWire protection for the virgin territory.

We report on three cases of left main stem thrombosis complicating percutaneous coronary angioplasty. We focused on the issue of dealing with emboli in the non-culprit vessel, as embolism in the "virgin" vessel is often associated with severe cardiogenic shock. We describe the use of a FilterWire technique to protect the non-culprit vessel and a case in which the FilterWire was occluded by thrombus leading to shock. The third case illustrates the difficulty with FilterWire protection if stenting is required in the left main stem itself.

Aldosterone receptor antagonism induces reverse remodeling when added to angiotensin receptor blockade in chronic heart failure.

OBJECTIVES: The objective of this study was to determine if adding spironolactone to an angiotensin II receptor blocker improves left ventricular (LV) function, mass, and volumes in chronic heart failure. BACKGROUND: Add-on spironolactone therapy substantially improves clinical outcomes among patients with severe heart failure (HF) on standard therapy. However, the value of combining spironolactone with an angiotensin II receptor blocker on LV reverse remodeling in mild-to-moderate systolic HF is unclear. METHODS: Fifty-one systolic HF patients with left ventricular ejection fraction (LVEF) <40% were randomly assigned to receive 1-year treatment of candesartan and spironolactone (combination group) or candesartan and placebo (control group). Reverse remodeling was assessed by serial cardiac magnetic resonance imaging and echocardiographic tissue Doppler imaging (TDI). RESULTS: There were significant improvements in LVEF (35 +/- 3% vs. 26 +/- 2%, p < 0.01) and reduction of LV end-diastolic volume index (121 +/- 16 ml/m2 vs. 155 +/- 14 ml/m2, p = 0.001), end-systolic volume index (88 +/- 17 ml/m2 vs. 120 +/- 15 ml/m2, p < 0.0005), and LV mass index (81 +/- 6 g/m2 vs. 93 +/- 6 g/m2, p = 0.002) in the combination group at 1 year. In addition, there was significant increase in peak basal systolic velocity and strain by TDI, decrease in index of filling pressure, and increase in cyclic variation integrated backscatter. In the control group, there were no significant changes in all these parameters after 1 year. CONCLUSIONS: The addition of spironolactone to candesartan has significant beneficial effects on LV reverse remodeling in patients with mild-to-moderate chronic systolic HF.

Correlation of T-cell immune response with spontaneous resolution and subsequent relapse of Hodgkin's lymphoma.

To our knowledge, there has been no report of spontaneous regression in a non-immunocompromised adult with classical Hodgkin's lymphoma (HL) in the absence of chemotherapy. We describe spontaneous regression and subsequent relapse of Epstein - Barr virus (EBV)-positive HL in an otherwise healthy male adult. The clinical course was associated with an increase in regulatory T-cell markers within the peripheral blood and diseased lymph node at the time of relapse and with a concomitant reduction in cellular immunity against relevant EBV latent membrane protein tumor-associated antigens. Our findings are in keeping with previous observations that implicate impaired cellular immunity in the immunopathogenesis of EBV-positive HL.

Some personality correlates of using eBay.

The use of eBay by 102 American undergraduate students was not associated with competitiveness, locus of control scores, or money attitude scores.

Stent restenosis in a Chinese population.

BACKGROUND: Stents are now widely used in Hong Kong and China and there is a clinical impression that restenosis is less common because of the lower prevalence of coronary artery disease and associated risk factors in the Chinese. However, there are no published data on angiographic stent restenosis rates in Chinese patients. METHOD: In a prospective study of 114 consecutive Chinese patients who underwent coronary stenting, quantitative coronary analyses were made at the time of stent implantation and subsequently at 6 months post-stenting (n = 97). RESULTS: At 6 months, restenosis (> or = 50% diameter stenosis in the dilated segment) was present in 42 (43.3%) of the 97 patients and 54 (33.5%) of the total 161 lesions stented. Vessel reference diameter (VRD) of < 3 mm and stented length of > or = 18 mm were associated with higher restenosis rates (36% and 38%). Compared to those without, those with restenosis had a greater residual stenosis of 16.53+/-11.54% and smaller final minimal luminal diameter (MLD) of 2.41+/-0.49 mm, (p < 0.01 and p < 0.008 respectively). Standard coronary risk factors were not associated with a higher rate of restenosis. Lesion morphology was significantly associated with restenosis. CONCLUSION: Coronary stenting in Hong Kong Chinese patients is associated with a restenosis rate comparable to that demonstrated in previously published trials from populations in the West.

Analysis of clinical outcomes following in-hospital adult cardiac arrest.

AIMS: The outcome of in-hospital resuscitation following cardiac arrest depends on many factors related to the patient, the environment and the extent of resuscitation efforts. The aim of the present study was to determine predictors of successful resuscitation and survival to -hospital discharge following in-hospital cardiac arrest and to assess functional outcomes of survivors (cerebral performance scores). METHODS: Medical records of adult patients sustaining in-hospital cardiac arrest between June 2001 and January 2003 were reviewed. Successful resuscitation was defined as the return of spontaneous circulation at the completion of resuscitative efforts, irrespective of degree of inotropic/vasopressor support. Thirty demographic and clinical variables were analysed to determine predictors of successful resuscitation and in-hospital survival. RESULTS: In 105 patients with cardiac arrest, 46 patients (44%) were successfully resuscitated and 22 (21%) survived to hospital discharge. Predictors of successful resuscitation included a primary cardiac admission diagnosis, monitoring at the time of the arrest, a longer duration of resuscitation and the absence of the need for endotracheal intubation. Patients with ventricular tachycardia/fibrillation were more likely to survive to hospital discharge than those with asystolic or pulseless electrical activity (45 vs 12 vs 20%, P = 0.01). The sole independent predictor of survival to hospital discharge was the absence of the need for endotracheal intubation (odds ratio 0.14, 95% confidence interval 0.02-0.88, P < 0.01). The majority of survivors (73%) had normal cerebral performance scores. CONCLUSIONS: Identification of predictors of successful resuscitation following cardiac arrest is important for risk stratification. Ongoing appraisal of in-hospital cardiac arrests through a multicentre registry could improve clinical outcomes.

Effect of N-acetylcysteine for prevention of contrast nephropathy in patients with moderate to severe renal insufficiency: a randomized trial.

BACKGROUND: The effect of N-acetylcysteine (NAC) to prevent contrast nephropathy (CN) in patients with moderate to severe renal insufficiency undergoing coronary angiography or interventions is not clear. METHODS: This is a prospective, open-label, randomized, controlled trial. Ninety-one consecutive patients with a serum creatinine level of 1.69 to 4.52 mg/dL (149 to 400 micromol/L) undergoing coronary procedures were recruited and randomly assigned to administration of either oral NAC, 400 mg, thrice daily the day before and day of the contrast procedure (the NAC group) or no drug (the control group). Serum creatinine was measured before and 48 hours after contrast exposure. The primary end point of this study was the development of CN, defined as an increase in serum creatinine concentration of 0.5 mg/dL or greater (> or =44 micromol/L) or a reduction in estimated glomerular filtration rate (GFR) of 25% or greater of the baseline value 48 hours after the procedure. RESULTS: There were no significant differences between the 2 groups (46 patients, NAC group; 45 patients, control group) in baseline characteristics or mean volume of contrast agent administered. Six patients (13.3%) in the control group and 8 patients (17.4%) in the NAC group developed CN (P = 0.8). Serum creatinine levels increased from 2.27 +/- 0.54 to 2.45 +/- 0.65 mg/dL (201 +/- 48 to 217 +/- 57 micromol/L; P = 0.003) in the NAC group and 2.37 +/- 0.61 to 2.40 +/- 0.70 mg/dL (210 +/- 54 to 212 +/- 62 micromol/L; P = 0.6) in the control group. The increase in serum creatinine levels between the 2 groups had no difference (P = 0.7). Estimated GFR decreased from 30.3 +/- 8.4 to 28.1 +/- 8.4 mL/min (P = 0.01) in the NAC group and 28.4 +/- 8.6 to 27.5 +/- 8.8 mL/min (P = 0.3) in the control group. The decline in estimated GFR between the 2 groups had no difference (P = 0.7). CONCLUSION: In the current study, oral NAC had no effect on the prevention of CN in patents with moderate to severe renal insufficiency undergoing coronary angiography or interventions. However, the sample size of our present study is small. Our findings highlight the need for a large-scale, randomized, controlled trial to determine the exact beneficial effect of NAC.

CAT/CLAMS: its use in detecting early childhood cognitive impairment.

The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS), a neurodevelopmental tool for the cognitive assessment of infants and toddlers, correlates well with the Bayley Scales of Infant Development. In 1993 the Bayley Scales were revised and the second edition published (BSID-II). This study was designed to determine how well the CAT/CLAMS correlates with the BSID-II and its utility in identifying mild and severe cognitive impairment. Sixty-eight infants and toddlers (age range = 14-48 months), referred for suspected developmental delays, were administered the CAT/CLAMS and BSID-II and the results compared. The correlation between the two instruments was strong (r = 0.89, P<0.0001). The CAT/CLAMS was sensitive (81%) and specific (85%) for detecting overall cognitive impairment (BSID-II less than 70) and was even more sensitive (100%) and specific (96%) in detecting severe cognitive impairment (BSID-II less than 50). The physician using the CAT/CLAMS formulated a clinical impression of cognitive impairment that was sensitive (95%) and specific (84%) compared with formal psychologic testing. The CAT/CLAMS correlates well with the BSID-II. It is useful for detecting and quantifying mild and severe cognitive impairment. It permits the physician to formulate an accurate clinical impression of cognitive impairment consistent with possible mental retardation.

Preventing dehydration in children with cystic fibrosis who exercise in the heat.

PURPOSE: In healthy children who exercise in the heat, the addition of flavor, carbohydrate, and 18 mmol x L(-1) NaCl to water induced a major increase in voluntary drink intake compared with the intake of unflavored water. This increase was sufficient to prevent voluntary dehydration. We hypothesized that, to achieve a similar effect in children with cystic fibrosis (CF), whose NaCl losses in sweat are markedly excessive, the drink should include an NaCl concentration higher than 18 mmol x L(-1). METHODS: Eleven subjects with CF (6 girls, 5 boys, ages 10.9-19.5 yr) attended three 3-h sessions of intermittent exercise of moderate intensity (four 20-min bouts), at 35 degrees C, 50% relative humidity. Either water (W), flavored water (FW), or a 30 mmol x L(-1) NaCl plus 6% carbohydrate solution (Na30) was offered ad libitum, in a counterbalanced sequence. Six subjects performed an additional session in which they drank a 50 mmol x L(-1) NaCl-6% CHO solution (Na50). RESULTS: There was no significant drink effect on body fluid balance, core temperature, heart rate, or serum electrolytes with W, FW, or Na30. Serum osmolality decreased throughout the sessions from 290.6 +/- 1.1 (mean +/- SEM) to 281.3 +/- 1.2 mmol x kg(-1) (P < 0.0005), serum sodium from 143.1 +/- 0.5 to 141.1 +/- 0.7 mmol x L(-1) (P = 0.01) and serum chloride from 109.1 +/- 0.5 to 107.5 +/- 0.5 mmol X L(-1) (P < 0.001). In contrast, the 50 mmol x L(-1) NaCl drink induced a near significant (P = 0.08) higher fluid intake, and it significantly ameliorated the rate of progressive dehydration. CONCLUSIONS: The marked loss of NaCl in the sweat of CF patients may induce an hypo-osmolar state in the serum, even when the drink contains 30 mmol x L(-1) NaCl. This may diminish the thirst drive triggered by hypothalamic osmoreceptors and may lead to voluntary dehydration. A flavored drink with an even higher salt content (50 mmol X L(-1)), however, enhances drinking and attenuates the voluntary dehydration.

Gastrointestinal parasitic infection, anthropometrics, nutritional status, and physical work capacity in Colombian boys.

This article tests the hypothesis that the presence of gastrointestinal parasites in Colombian boys is negatively associated with anthropometric characteristics, physical work capacity, blood hemoglobin (Hb) levels, and nutritional status. Anthropometric, Hb, &Vdot;O(2) max, and parasite load data were collected on 1,016 boys in Cali, Colombia. The boys were classified as lower socioeconomic class (SEC) from either urban or rural environments, and upper SEC from an urban environment. Sixty-three percent of the boys were infected with gastrointestinal parasites and, of the infected boys, 80-95% had light parasite loads. Parasites found included Necator americanus, Ascaris lumbricoides, Entamoeba histolytica, Trichuris trichiura, Giardia spp., and Enterobius vermicularis. Infected boys had significantly lower weight, stature, weight-for-height (among 6-9-year-old boys), Hb levels, and &Vdot;O(2) max (ANCOVA, controlling for age and SEC). In terms of nutritional status, infected boys were 1.47 times more likely to be classified as iron deficient than noninfected boys (chi-square, P < 0.001), and 1.61 times more likely to be classified as stunted (P < 0.001). Infection was not associated with wasting in any SEC group. In conclusion, light to moderate gastrointestinal parasite loads were associated with significantly lower weight, stature, weight-for-height (in 6-9-year-old boys), Hb levels, and &Vdot;O(2) max, and a significantly higher frequency of IDA and stunting. These data suggest that comprehensive analyses of the nutritional status of populations in regions endemic for parasitic infection should include testing for the presence of infection. Am. J. Hum. Biol. 11:763-771, 1999. Copyright 1999 Wiley-Liss, Inc.