Mitral regurgitation: when to intervene? : A historical perspective.

Although mitral regurgitation (MR) is the most common valvular heart disease, it should be regarded as a complex multifactorial disease that involves multiple entities. Optimal medical therapy alone does not hinder the progression of the disease, and in the 1980s it was already recognised that corrective surgery is indicated if MR is severe and patients are symptomatic (except for those with the most severe left ventricle dysfunction). Later on, asymptomatic patients with deterioration of the left ventricular ejection fraction were also operated on to avoid irreversible left ventricular dysfunction, heart failure and eventually death. However, a major drawback remains the fact that a significant group of patients is considered to have a high perioperative risk due to their advanced age or severe comorbidities. Since less invasive, percutaneous interventions have been developed and recently thoroughly investigated in the MITRA-FR and the COAPT studies, the type of intervention and also the timing have become more crucial. In this critical review of the literature, we describe what we should have learned from the past and which (haemodynamic) parameters can best predict the outcome in patients with MR.

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals.

PURPOSE: To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: For every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI. RESULTS: The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively. CONCLUSIONS: Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach.

Planning and monitoring of patients for electrical cardioversion for atrial fibrillation.

OBJECTIVES: This study evaluated the waiting list for elective electrical cardioversion (ECV) for persistent atrial fibrillation (AF), focusing on when and why procedures were postponed. We compared the effects of management of the waiting list conducted by physicians versus management by nurse practitioners (NPs) and we evaluated the safety of our anticoagulating policy by means of bleeding or thromboembolic complications during and after ECV. BACKGROUND: Not all patients selected for ECV receive their treatment at the first planned instance due to a variety of reasons. These reasons are still undocumented. METHODS: We evaluated 250 consecutive patients with persistent AF admitted to our clinic for elective ECV. RESULTS: Within 5 to 6 weeks, 186 of 242 patients (77%) received ECV. The main reason for postponing an ECV was an inadequate international normalised ratio (INR); other reasons included spontaneous sinus rhythm and switch to rate control. A total of 23 of the 147 patients (16%) managed by the research physician were postponed due to an inadequate INR at admission versus 4 out of 98 patients (4%) managed by NPs (p = 0.005) CONCLUSION: An inadequate INR is the main reason for postponing an ECV. Management of ECV by NPs is safe and leads to less postponing on admission.

Life-threatening bilateral aorto-ostial coronary artery disease in an octogenarian.

Aorto-ostial disease is difficult to approach percutaneously; therefore, a surgical option may be more desirable. We describe a case of an octogenarian in which the clinical arguments and technical approach have been summarised for a successful percutaneous therapeutic strategy. (Neth Heart J 2009;17:30-2.).

Visualization of anomalous coronary arteries on dual-source computed tomography.

The purpose of this study is to assess the capability of dual-source computed tomography (DSCT) in evaluating coronary artery anomalies. Early detection and evaluation of coronary artery anomalies is essential because of their potential association with myocardial ischemia and sudden death. In 16 patients (12 men, mean age 50 +/- 14 years), anomalous coronary arteries were detected on contrast-enhanced DSCT in a patient cohort of 230 individuals (incidence of 7%). Six different types of anomalies were diagnosed (three fistula, four anomalies of the circumflex artery, four anomalous right coronary arteries, three anomalies of the left coronary artery, one absent left main coronary artery, and one left coronary artery arising from the pulmonary trunk). Of the 16 patients, 10 also underwent conventional coronary angiography (CAG). Retrospective evaluation of the CAGs by an experienced interventional cardiologist resulted in a precise diagnosis in 50% of patients. With DSCT, sufficient image quality and exact visualization of the aberrant anatomy were achieved in all patients. Therefore, DSCT seems to be an accurate diagnostic tool for examining the precise origin, course, and shape of aberrant coronary arteries.

Closure of the femoral artery after cardiac catheterization: a comparison of Angio-Seal, StarClose, and manual compression.

OBJECTIVES: To compare Angio-Seal (AS) and StarClose (SC) and manual compression (MC) on efficacy of hemostasis, complication rate, safety of early mobilization, and patient comfort. BACKGROUND: Closure of the femoral artery after cardiac catheterization can be obtained through different methods. Today, physicians can choose from a number of different devices to achieve arterial closure. METHODS: In a prospective trial 450 patients were randomized to AS, SC, or MC. Patients were mobilized 1 to 2 hr after device placement, and 6 hr after MC. Data were collected during hospital admission and by telephone at one month after hospital discharge. RESULTS: Devices were used in 138/150 allocated to AS and 124/150 allocated to SC patients (92% vs. 83%, P = 0.015) Patients with MC experienced more pain during sheath removal than patients receiving a device, and rated their period of bed rest as less comfortable. Oozing and need for pressure bandage at the puncture site were observed in 37 AS patients and 57 SC patients (25% vs. 38%, P = 0.002). Hematoma occurred in 15 AS patients, in 17 SC patients, and in 14 MC patients (11 vs. 14 vs. 9%, ns). CONCLUSION: There is no difference in safety between the three methods of arterial closure. SC was more often not used or successfully deployed. SC patients more often had continuing oozing. On patient comfort, closure devices performed better than MC. Early ambulation in patients with a closure device is safe. AS is the preferred method of arterial closure after cardiac catheterization.

Haemodynamic patterns in ST-elevation myocardial infarction: incidence and correlates of elevated filling pressures.

OBJECTIVES.: We sought to study the incidence and clinical correlates of elevated filling pressures in ST-elevation myocardial infarction (STEMI) patients, without physical signs of heart failure and treated with primary coronary angioplasty. BACKGROUND.: Haemodynamic data, as measured with a Swan-Ganz catheter, are not routinely obtained in STEMI patients. At admission, low blood pressure, increased heart rate, sweating, increased respiration rate, rales, oedema, and a third heart sound are indicative of heart failure. METHODS.: All consecutive STEMI patients were monitored by a Swan-Ganz catheter and central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure (PAS) and cardiac index (CI) were measured. To investigate the clinical correlates of the haemodynamic status patients were classified according to previously defined haemodynamic criteria. RESULTS.: We studied 90 patients, aged 60.5+/-13.1 year, 76% were male. Mortality at 30 days was 2/90 (2.2%). Patients with impaired haemodynamics presented later and had larger myocardial infarct sizes. CVP, PCWP and PAS were above normal in 36 (40%) patients. CONCLUSION.: A large proportion of STEMI patients without physical signs of heart failure have elevation of right- as well as left-sided cardiac filling pressures. (Neth Heart J 2007;15:95-9.).

Aortic dissection presenting as acute myocardial infarction: potential harm of antithrombin and antiplatelet therapy.

In the treatment of acute myocardial infarction, antithrombin and antiplatelet therapy are indicated according to the current guidelines. When a patient presents with symptoms and signs of acute myocardial infarction, an extensive list of diagnoses should be considered. Because of the nonspecific symptoms of aortic dissection, the disease may be easily misdiagnosed. A high clinical suspicion of aortic dissection is therefore required. Once aortic dissection has been diagnosed, surgical intervention provides the only definitive treatment for these patients, regardless of antithrombin and antiplatelet therapy.

Evaluation of haemodynamics by cardiac catheterisation: historical perspective and present practice.

In 1956, three men were awarded the Nobel Prize in Physiology or Medicine, in particular 'for their discoveries concerning heart catheterisation and pathological changes in the circulatory system'. Their names in alphabetical order: André F. Cournand, Werner Forssmann and Dickinson W. Richards. Forssmann's experiment dated from 1929, while Cournand and Richards started their work in 1941. The order in which they presented their Nobel lectures on 11 December 1956 was Forssmann, Richards, Cournand.

Validation of Fick cardiac output calculated with assumed oxygen consumption: a study of cardiac output during epoprostenol.

OBJECTIVE: To test the validity of using assumed oxygen consumption for Fick cardiac output during administration of epoprostenol. METHODS: In 24 consecutive patients Fick cardiac output calculated with assumed oxygen consumption according to LaFarge and Miettinen (COLM) and according to Bergstra et al. (COBE) were compared with thermodilution cardiac output (COTH). Pulmonary vascular resistance (PVR) was calculated with each cardiac output (CO) value. If PVR exceeded 200 dyne.s.cm-5, administration of epoprostenol (Ep) was started, and at maximal dose the above-mentioned measurements were repeated. RESULTS: In all 24 patients COBE agreed significantly with COTH, mean difference -0.145 1.min-1, 95% confidence interval (CI) -0.402 to 0.111, limits of agreement (LA) -1.336 to 1.045. COLM was significantly lower than COTH, -1.165 1.min-1, p<0.05, 95% CI -1.510 to -0.819, LA -2.768 to 0.438. In 16 patients (67%) administration of epoprostenol was indicated. During Ep infusion the CO values calculated with oxygen consumption according to LaFarge and Miettinen (EpCOLM) were also significantly lower than thermodilution CO (EpCOTH), mean difference -1.281 1.min-1, p<0.05, 95% CI -1.663 to -0.900, LA -2.685 to 0.122. The agreement of CO values calculated with oxygen consumption according to Bergstra et al. (EpCOBE) and EpCOTH remained, mean difference -0.115 1.min-1, 95% CI -0.408 to 0.178, LA -1.191 to 0.962. CONCLUSION: Before as well as during administration of epoprostenol, it is justified to use CO values calculated with oxygen consumption according to Bergstra et al. instead of thermodilution CO; CO values calculated with oxygen consumption according to LaFarge and Miettinen show significant underestimation.