Gender-related differences in side-effects and hemodynamic response to regadenoson in patients undergoing SPECT myocardial perfusion imaging.

PURPOSE: To evaluate differences in side-effects and hemodynamic response between men and women undergoing regadenoson-stress SPECT myocardial perfusion imaging (MPI). METHODS: The initial population of the study included 858 consecutive patients who underwent regadenoson-stress MPI at our institution. These patients underwent prospective assessment and classification of regadenoson-induced side-effects in six categories and recording of heart rate (HR) and blood pressure (BP) before and after regadenoson administration. From this initial population, after adjustment with 1:1 propensity matching using gender as the dependent variable and age, BMI, diabetes mellitus, hypertension, smoking, presence of coronary artery disease, LVEF, baseline systolic and diastolic blood pressure (BP) and HR, on-going use of cardio-active medications during test, and abnormal MPI scan as independent variables, a population of 279 pairs of opposite gender was formed and studied. RESULTS: Compared with men, women had a significantly higher rate of any side-effect (71% vs. 58%, p = 0.002), chest pain (23% vs. 12%, p < 0.001), gastrointestinal discomfort (20% vs. 12%, p = 0.01), dizziness (12% vs. 5%, p = 0.002), and headache (20% vs. 13%, p = 0.03) and similar rates of dyspnea and other side-effects. Women demonstrated a higher median HR-response compared with men (41% (- 8, 127) vs. 34% (- 5, 106), p = 0.001) while men demonstrated a lower median systolic BP response (- 3% (- 27, 48) vs. 0% (- 36, 68), p = 0.02) compared with women. CONCLUSIONS: Gender is independently associated with a differential response to regadenoson with regard to overall side-effects and HR-response. These observations have the potential of important management and prognostic implications respectively.

Pulmonary arterial hypertension associated with interferon-beta treatment for multiple sclerosis. Case report and literature review.

Drug-Induced Pulmonary Arterial Hypertension (PAH) represents a well-known entity, predominantly related to anorexigens. Interferon-ß (IFN) is considered to be a drug with a possible risk of inducing PAH. We report a patient with Multiple Sclerosis treated with IFN-ß who diagnosed with PAH and her course of disease under specific PAH drug therapy. A review of the literature in IFN-ß-induced PAH is provided.

Anesthetic management of patients undergoing transcatheter aortic valve implantation.

OBJECTIVE: To compare 2 anesthetic techniques, general anesthesia or monitored anesthesia care, performed by the same cardiac anesthesiologists for transcatheter aortic valve implantation in the authors' institution. DESIGN: A retrospective study. SETTING: A single specialized cardiac surgery center. PARTICIPANTS: Ninety-eight patients with severe aortic valve stenosis and a high logistic EuroSCORE considered not eligible to undergo conventional aortic valve replacement. INTERVENTION: General anesthesia or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: General anesthesia was used in 57 and monitored anesthesia care in 41 patients. The authors compared the following parameters: Duration of procedure, transfusion requirements, cardiac indices, superior vena cava saturation (ScVO2) before and after the aortic valve implantation, hospital length of stay and 30-day mortality. The only significant differences between the groups concerned were the duration of anesthesia (p<0.001) and ScVO2 values. Anesthesia duration was prolonged significantly when general anesthesia was administered, and ScVO2 was significantly higher both before and after the valve implantation in the general anesthesia group. Thirty-day mortality was 5.3% in the general anesthesia group and 4.9% in the monitored anesthesia group. CONCLUSIONS: It would appear that both anesthetic techniques may be used for patients with a high logistic EuroSCORE undergoing transcatheter aortic valve implantation.

Inferior epigastric artery as a landmark for transfemoral TAVI. Optimizing vascular access?

OBJECTIVES: This study sought to investigate whether the site of common femoral artery (CFA) cannulation in regard to the inferior epigastric artery (IEA) is associated with the incidence of vascular complications in patients undergoing transfemoral aortic valve implantation (TAVI). BACKGROUND: Vascular access complications are a main issue during TAVI and have been associated with significant increase of morbidity and mortality. The need for establishment of reliable predictors for these serious events remains important. METHODS: A total of 90 patients, who had undergone TAVI, were retrospectively studied. Vascular complications were defined as major and minor according to the Valve Academic Research Consortium (VARC) criteria. Patients were divided into high cannulation site (CS) group and low CS group depending on the common femoral artery puncture site position, in regards to the most inferior border of the IEA. RESULTS: Vascular complications were significantly more frequent in the high CS group versus the low CS group (32.3% vs. 11.9%, P = 0.039). High cannulation remained an independent predictor of vascular complications after adjustment for known risk factors (OR: 4.827, CI: 1.441-16.168; P = 0.011). CONCLUSIONS: In patients undergoing transfemoral TAVI, arterial puncture above the most inferior border of the IEA is associated with vascular complications.

Effect of combined chelation therapy with deferiprone and deferoxamine on left ventricular diastolic function in adult beta-thalassemia major patients.

Beta-thalassemia major (beta-TM), patients, asymptomatic and with preserved left ventricular ejection fraction (LVEF) were studied echocardiographically. Group A (26 patients), on deferiprone (L1) and deferoxamine (DFO) combination therapy (L1: 80 +/- 27 mg/kg/day, DFO: 160 +/- 87 mg/kg/week) and group B (35 patients) on DFO monotherapy (240 +/- 40 mg/kg/week) for the last 2 years were compared. Another group, C (14 patients), switched to L1 (74 +/- 15 mg/kg/day) plus DFO (158 +/- 48 mg/kg/week) for 20-30 months, was prospectively studied for 2 years. In group A, MRI T2* values were increased and improved in group C during follow-up. The LVEF was better in group A than in group B, while such an improvement was also detected in the group C follow-up study. The Tissue Doppler study E' velocity and E/E' ratio was not different. Similarly, in the group C follow-up no significant change in E/E' ratio was detected. It seems that although LVEF significantly improves with combined therapy, diastolic function indexes do not show a similar change.

Predictive value of cardiac autonomic indexes and MIBG washout in ICD recipients with mild to moderate heart failure.

OBJECTIVE: We aimed at evaluating the combined use of heart rate variability (HRV), baroreflex sensitivity (BRS), and MIBG imaging in the risk stratification for sudden cardiac death (SCD) of patients with mild to moderate heart failure. METHODS: Twenty-five patients (17 male and 8 female, mean age 63 +/- 5 years, mean LVEF 36 +/- 3%) with a recently implanted defibrillator (ICD) and mild (NYHA I-II) heart failure due to either ischemic (n = 15) or dilated (n = 10) cardiomyopathy were studied. One week after ICD implantation they underwent (a) baroreflex sensitivity (BRS) evaluation to bolus phenylephrine by the Oxford method, (b) 24-h heart rate variability (HRV) assessment, and (c) MIBG imaging. The mean patient follow-up was 32 +/- 10 months. Simple correlation and stepwise multiple regression analysis was performed to evaluate (a) if the number of sustained ventricular tachycardia (cycle length <330 ms) or fibrillation episodes per month is related to one or more of MIBG, BRS, and HRV indexes and (b) if MIBG % washout is related to HRV and/or BRS. RESULTS: The frequency of fast ventricular arrhythmic episodes (FVAE) demonstrated an inverse relation to BRS (p < 0.0001), rMSSD (p = 0.001), and pNN50 (p = 0.0034), while it was positively related to LF (p < 0.0001) and MIBG % washout (p = 0.001). BRS, LF, rMSSD, and MIBG washout were also independent predictors of FVAE. MIBG washout was related to only one HRV marker (SDNN-I, p < 0.0001), while no correlation was observed with BRS. CONCLUSIONS: In ICD recipients with well-compensated heart failure, autonomic markers derived from BRS, HRV, and MIBG studies are related to FVAE. These markers have limited inter-dependency and constitute useful means for SCD risk stratification in this subgroup of patients.

Procalcitonin in acute myocardial infarction.

OBJECTIVE: Procalcitonin (PCT) is released in severe bacterial infections, sepsis and in infection independent cases such as major surgery, multiple trauma, cardiogenic shock, burns, resuscitation, and after cardiac surgery. The aim of this study was to determine the levels and the kinetics of PCT in AMI and to investigate their possible correlation with the release of IL-6 and CRP. DESIGN-PATIENTS: The study included 60 patients (47 men, 63.2+/-14.8 years) with the diagnosis of AMI at admission. In all patients, serum levels of PCT, IL-6, CK-MB, TnI and CRP were measured at admission, at 3, 6, 12, 24, 48 and 72 h and at the seventh day. RESULTS: PCT was elevated in all patients with AMI. It was initially detected in serum approximately 2-3 h after the onset of the symptoms. The median value at admission was 1.3 ng/ml (95% CI: 0.89 to 1.80). The value of PCT showed an increase and reached a plateau after 12-24 h. The median value at 24 h was 3.57 ng/ml (95% CI: 2.89 to 4.55). PCT values fell to baseline (<0.5 ng/ml) by the seventh day. PCT was detected in serum earlier than CK-MB or TnI in 56 of the 60 patients (93.3%). The kinetics of PCT was similar to those of CK-MB and TnI. The maximal values of PCT were positively correlated with the maximal values of IL-6 (r = 0.59, P = 0.00) and of CRP (r = 0.65, P = 0.001). The maximal values of IL-6 were positively correlated with max CRP (r = 0.35, P = 0.045). CONCLUSIONS: PCT could be considered as a novel sensitive myocardial index. Its release in AMI is probably due to the inflammatory process that occurs during AMI.

Coronary flow evaluation by TIMI frame count and magnetic resonance flow velocity in patients with coronary artery ectasia.

PURPOSE: Coronary artery ectasia (CAE) is defined as a dilatation of an arterial segment to a diameter at least 1.5 times that of the adjacent artery. It is characterized by slow flow, predisposing to thrombosis. The TIMI frame count (TFC) technique has been successfully used for the assessment of coronary flow velocity using coronary angiograms (CA). Our aim was to compare TFC with magnetic resonance peak flow velocity (PFV) for the evaluation of the coronary flow in patients with CAE. METHODS: Fifteen male patients with CAE, aged 45-60 yrs, and 15 age-matched male controls were studied by both techniques. Only patients without coronary obstructive disease were included. Magnetic resonance coronary angiography (MRA) was performed with a 1.5T scanner. The most ectatic part of the proximal 1/3 of the vessel involved was examined. Velocity-encoded MR images were acquired in a double oblique imaging plane, which was perpendicular to the same ectatic segment. The findings were compared with TFC results. RESULTS: Ten patients had RCA ectasia and five LAD ectasia. In CAE patients, peak flow velocity was 10.7 +/- 1.4 cm/sec in RCA and 11.4 +/- 2.3 cm/sec in LAD. TFC was 42.9 +/- 7.4 in RCA and 52.0 +/- 20.1 in LAD. In controls, peak flow velocity was 18.1 +/- 1.9 in RCA and 21.0 +/- 1.7 cm/sec in LAD. TFC was 20.4 +/- 1.59 in RCA and 19.8 +/- 1.12 in LAD. Controls had significantly higher peak flow velocity (p < 0.001) and lower TFC (p < 0.001) in both RCA and LAD, compared to patients with CAE. In patients with CAE, there was a negative correlation between PFV and TFC measurements (r = -0.74, p < 0.001). CONCLUSION: Coronary flow in CAE patients can be assessed both by TFC and PFV. The noninvasive nature of PFV gives the opportunity for serial, easily repeatable, flow evaluation in these patients.

Outcome of percutaneous mitral balloon valvuloplasty: comparison of the inoue and retrograde non-transseptal techniques. A single-center experience.

INTRODUCTION: The transseptal Inoue (IN) and to a lesser extend retrograde non-transseptal (RNT) techniques are established procedures for percutaneous mitral balloon valvuloplasty (PBMV) in patients with mitral stenosis. However, a head to head comparison of these two techniques, especially from a single center, has not yet been reported. METHODS: Seventy-two consecutive patients (n = 35 IN and n = 37 RNT) underwent PMBV in our clinic from October 1993 to December 1999. All baseline and procedural characteristics were compared, as well as immediate and long-term outcomes (mean follow-up, 42 12 months) of the patients. RESULTS: Baseline characteristics were similar in the two groups. A successful immediate result was achieved in 91% of IN patients and 89% of RNT patients. After the PMBV, mitral valve area (MVA) increased from 1.04 0.16 cm2 to 1.6 0.3 cm2 and from 1.06 0.23 cm2 to 1.55 0.3 cm2 in the IN group and RNT group, respectively (p = NS). There was a higher percentage of mild mitral regurgitation (MR) after the RNT technique (p = 0.03). Mean fluoroscopy time was 31 16 minutes in the IN group and 39 11 minutes in the RNT group (p = 0.02). After discharge, major adverse cardiac events (MACE: mitral valve replacement, repeat PMBV) occurred in 3 patients (8%) patients in the IN group and 5 patients (13.5%) in the RNT group (p = NS). Follow-up echocardiographic evaluation revealed no significant changes regarding MVA in either group. CONCLUSIONS: The IN and RNT techniques are comparable regarding the achieved MVA, with slightly more frequent MR post-RNT PBMV. IN requires significantly less fluoroscopy time. MACE and event-free survival rates at follow-up were similar in the two groups.