Vernakalant and electrical cardioversion for AF - Safe and effective.

AIMS: Rapid restoration of sinus rhythm is an integral part of the management of recent-onset atrial fibrillation. We aimed to assess safety and efficacy of vernakalant, a multi-channel blocking agent, in combination with external electrical cardioversion. METHODS: This prospective cohort study comprised 230 patients (female 35%; median age 50 IQR 42-55) with recent-onset AF presenting to a university tertiary care center during a 6-year period. Management included intravenous vernakalant followed by electrical cardioversion in case of pharmacological failure. RESULTS: Within 11 min (IQR 8-29), sinus rhythm could be restored by sole pharmacological management in 167 patients (73%). A left ventricular function lower than 55% (OR 3.51 (1.45-8.52)) and prior atrial fibrillation episodes being classified as persistent (OR 2.33 (1.13-4.80)) were significant predictors for non-response to vernakalant. Electrical cardioversion was successful in all patients but one within 196 min (IQR 149-300) of administration of first dosage of vernakalant. No serious adverse events could be observed. 3 patients needed further in-patient care. CONCLUSION: Management of recent-onset atrial fibrillation consisting of intravenous vernakalant followed by electrical cardioversion in case of failure appears safe and efficacious. Achieving a rapid conversion, this approach could potentially save resources and costs.

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.

OBJECTIVES: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS: Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS: Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS: ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.

The role of ST-segment elevation in lead aVR in the risk assessment of patients with acute pulmonary embolism.

UNLABELLED: BACKGROUD AND AIM: Patients with acute pulmonary embolism (APE) present with highly variable symptoms and ECG abnormalities. As ST-elevation in lead aVR has recently been described to predict right ventricular dysfunction (RVD), we aimed to correlate this sign to the severity of APE. METHODS: Three-hundred ninety-six consecutive patients (in centers a and b) with proven APE were retrospectively analysed with respect to 12-lead-ECG, symptoms, thrombus location, echocardiograpy, troponin T, initial therapy and outcome. Data were then compared between patients with and without aVR-ST-elevation. RESULTS: On admission aVR-ST-elevation was present in 34.3% (n = 136). Presence of aVR-ST-elevation was assossiated with more severe clinical presentation (dyspnoea at rest 44.9 vs. 29.2%; p = 0.002, hypotension 17.0 vs. 6.5%; p = 0.001, syncope 16.2 vs. 6.5%; p = 0.002), higher median troponin T levels (0.035 [0.01-0.2] versus 0.01 [0.01-0.02]; p < 0.001), more frequent RVD (74.5 vs. 46.6%; p < 0.001) and central located thrombi (50.8 vs. 29.2; p < 0.001). Thrombolysis was used more frequently (29.1 vs. 7.5%; p < 0.001) and in-hospital-mortality was increased (10.3 vs. 5.4%; p = 0.07) when compared to patients without that sign. Mortality in intermediate-risk APE patients with aVR-ST-elevation was 8.9% compared to 0% in those without (p = 0.04). In contrast, the presence of other classical ECG pattern of APE did not further increase mortality in intermediate-risk patients. CONCLUSIONS: ST-elevation in lead aVR is associated with a more severe course of APE, especially in patients with intermediate-risk. Therefore, aVR-ST-elevation might be useful in risk stratification of APE.

Pre-operative N-terminal pro-brain natriuretic peptide predicts outcome in type A aortic dissection.

BACKGROUND: Acute Stanford type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. OBJECTIVE: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a prognostic biomarker of outcome in cardiovascular disease. Its predictive power in patients undergoing emergency surgery for acute type A aortic dissection is yet unknown. METHODS: We prospectively measured pre-operative NT-proBNP in 104 patients (39 female, 35%; median age 61 years) undergoing emergency surgery for AAD during a 6-year study period. European System for Cardiac Operative Risk Evaluation risk scores were recorded and patients were followed for 30-day mortality and major adverse events (MAEs) as defined by the need for rethoracotomy, occurrence of postoperative heart failure, neurologic deficit, lung failure, renal failure, or sepsis. RESULTS: Median logistic European System for Cardiac Operative Risk Evaluation in the cohort was 12 (interquartile range 7 to 19). During the first 30 days, 23 patients (22%) died, and 53 patients (51%) experienced MAEs. Median (interquartile range) NT-proBNP levels in survivors versus nonsurvivors were 328 pg/ml (157 to 569) versus 2,240 pg/ml (515 to 4,734; p < 0.001), and in patients without versus with MAEs, 227 pg/ml (107 to 328) and 719 pg/ml (442 to 2,287; p < 0.001), respectively. Adjusted odds ratios for increasing tertiles of NT-proBNP compared with the lowest tertile were 0.98 (95% confidence interval [CI] 0.18 to 5.33; p = 0.98) and 11.67 (95% CI 2.61 to 52.09; p = 0.001) for 30-day mortality and 9.07 (95% CI 2.58 to 31.83; p = 0.001) and 50.21 (95% CI 10.85 to 232.45; p < 0.001) for MAEs, respectively, indicating a significant association between pre-operative NT-proBNP levels and outcome. CONCLUSIONS: Pre-operative NT-proBNP predicts outcome in patients undergoing surgery of AAD.

Acute chest pain--identification of patients at low risk for coronary events. The impact of symptoms, medical history and risk factors.

BACKGROUND: The evaluation of patients with acute chest pain remains challenging, as it implies the risk of fatal misdiagnosis. It is well recognized that typical angina does not specifically identify patients at high risk. We investigated the predictive value of characteristics atypical for myocardial ischemia for exclusion of acute or subacute coronary events, focusing on patients' symptoms, medical history and risk factors. METHODS: We prospectively studied 1288 consecutive patients presenting with acute chest pain at a non-trauma emergency department. Patients' symptoms, history and risk factors were evaluated using seven predefined criteria and assigned as typical or atypical for ischemic coronary chest pain. Positive predictive value (PPV) and 95% confidence intervals (95% CI) were calculated to predict or exclude acute myocardial infarction (AMI) and major adverse cardiac events (MACE: cardiovascular death, percutaneous coronary interventions, bypass surgery, or myocardial infarction) within six months. RESULTS: AMI occurred in 168 patients (13%), and 6-months MACE (including AMI) overall in 240 patients (19%). Presence of four or more criteria typical for myocardial ischemia was associated with a PPV of 0.21 (0.17 to 0.25) for predicting AMI and 0.30 (0.25 to 0.35) for 6-months MACE. Presence of four or more criteria atypical for coronary ischemia was associated with a PPV of 0.94 (0.91 to 0.96) for excluding AMI and 0.93 (0.90 to 0.96) for excluding 6-months MACE. In 165 of 476 patients under 40 years of age (35%), four or more atypical criteria excluded AMI and 6-months MACE with PPVs of 0.98 (0.96 to 1.0). CONCLUSION: Evaluation of criteria atypical for myocardial ischemia with acute chest pain may help to identify candidates for early discharge, whereas typical characteristics have very little diagnostic value.

[Surgical reduction of fat surplus leading to pulmonary embolism]. / Pulmonalembolie nach chirurgischer Fettreduktion.

Surgical reduction of fat surplus is usually performed on healthy individuals and is reported as a safe procedure as it is not associated with a lethal outcome. Due to the anticipation of peri- and postoperative bleeding as a result of the large wound area, which may have a negative influence on the cosmetic result, patients often receive no or only inadequate anticoagulation. We report three cases in which surgical reduction of fat surplus led to sudden collapse and cardiac arrest. In all of our patients, fatal pulmonary embolism was the cause of cardiac arrest. These patients received only inadequate or no anticoagulation. Early postoperative mobilization, elastic stockings and compressive wound-dressing did not prevent pulmonary embolism. In addition to early postoperative mobilization of the patient and even though there is a risk of perioperative bleeding complications, the use of anticoagulation is highly recommended in surgical procedures like abdominoplasty or dermolipectomy. If sudden dyspnea, chest pain, collapse or cardiac arrest occurs after surgical interventions like these, pulmonary embolism should be considered and further diagnostic steps should be initiated.

Misdiagnosis of pulmonary embolism in patients with allergic reaction--the importance of prior probability of disease.

Because pulmonary embolism (PE) and its treatment carry substantial risk of morbidity and mortality, accurate diagnosis is essential. We report two cases with allergic reactions, in which PE was suggested by routine ECG and D-dimer elevation and strengthened by spiral CT. Therapy with low-molecular-weight heparin was initiated and long-term anticoagulation was considered. As their histories did not reveal any predisposing factor to PE, the cases were re-evaluated. Elevation of D-dimer was now attributed to allergic reaction, ECG abnormalities were considered as constitutional, and findings from spiral CT attributed to breathing artifacts and partial-volume effects. The diagnosis of PE was therefore rejected and anticoagulant treatment discontinued without sequelae. These cases show the importance of determining clinical probability before ordering further diagnostic tests and critical interpretation of test results suggestive of PE, based on prior probability of the disease.

Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism.

OBJECTIVE: Thrombolytic therapy in patients with massive pulmonary embolism (MPE) and prolonged cardiopulmonary resuscitation (CPR) is subject to debate. This study was performed to determine whether (1) thrombolytic treatment increases the risk of bleeding complications, (2) if the risk of bleeding is influenced by the duration of CPR and if (3) thrombolytic therapy improves outcome. DESIGN: Retrospective cohort study. SETTING: Emergency department of a tertiary care university hospital. PATIENTS AND METHODS: Sixty-six patients with cardiac arrest (CA) due to MPE admitted between July 1993 and December 2001. Thirty-six patients received thrombolysis (TL) and were compared with 30 patients without thrombolytic therapy. Bleeding complications were assessed by clinical evidence or autopsy. RESULTS: Major bleeding complications appear to occur more frequently in patients treated with thrombolytics (9/36 (25%) vs. 3/30 (10%)) even though the difference was statistically not significant (P=0.15). It appears that CPR duration >10 min has no adverse impact on major bleeding complications. No difference in the rate of major bleeding complications between thrombolyzed patients who had a CPR duration of 10 min could be observed (2/8 (25%) vs. 7/28 (25%), P=0.99). In thrombolyzed patients a return of spontaneous circulation could be achieved more frequently (24/36 (67%) vs.13/30 (43%) in controls, P=0.06) and survival after 24 h was higher (19/36 (53%) vs. 7/30 (23%), P=0.01). Survival to discharge was also higher in the TL group (7/36 (19%) vs. 2/30 (7%)), but not statistically significant (P=0.15). CONCLUSION: Although severe bleeding complications tend to occur more frequently in patients undergoing TL, the benefit of this treatment might outweigh the risk of bleeding.

Mortality of patients with pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a potentially fatal disorder with highly varying mortality rates. To provide information that is more precise for prospective intervention studies, we analysed the data of our patients with PE, defining clinically relevant subgroups with respect to their individual mortality rates. METHODS: We studied 283 consecutive patients with confirmed PE diagnosis, with respect to demographic data, risk factors for thromboembolic disease and clinical signs. In addition, diagnostic and therapeutic interventions such as blood gas analysis (BGA), lactate and D-dimer determination, electrocardiography (ECG), echocardiography, spiral computer tomography (Spiral CT), ventilation/perfusion lung scintigraphy (V/Q-Scan), thrombolytic therapy, mechanical ventilation, and cardiopulmonary resuscitation (CPR), were accounted for. Study endpoint was mortality rates on day three. RESULTS: Overall, mortality rate was 15% (42 of 283). Mortality rates differed considerably; 95% of patients with cardiac arrest on arrival (21 of 22), 85% of patients with cardiac arrest--not in hospital (28 of 33), 80% of patients receiving mechanical ventilation (40 of 50), 77% of patients needing cardiopulmonary resuscitation within the first 24 hours (37 of 48), 37% of patients with syncope (18 of 49), 30% of patients receiving thrombolytic treatment (25 of 87), 26% of patients on whom lactate measurement was performed (36 of 139), 18% of patients on whom blood gas analysis was done (35 of 197), 17% of patients on whom echocardiography was performed (34 of 195), 8% of patients with twelve complete lead ECG recordings (21 of 262) and D-Dimer determination (12 of 148), 2% of patients tested on Spiral CT (5 of 226) and 1% where a V/Q-Scan was performed (1 of 74). CONCLUSION: Patients with PE who received mechanical ventilation, cardiopulmonary resuscitation, and thrombolytic treatment had very high mortality rates of 80, 77 and 30% respectively. However, patients stable enough for diagnostic procedures as Spiral CTs and V/Q-Scans had mortality rates of 1 to 2%. These facts are to be considered when planning pulmonary embolism intervention trials in which reduction of mortality is a defined endpoint.