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PURPOSE: To compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE). MATERIALS AND METHODS: The NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score-matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT. RESULTS: A total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT. CONCLUSIONS: CDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.
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Embolia Pulmonar , Terapia Trombolítica , Adulto , Humanos , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos , Fibrinolíticos , Readmissão do Paciente , Resultado do Tratamento , Embolia Pulmonar/terapia , Embolia Pulmonar/tratamento farmacológico , Catéteres , Hemorragias Intracranianas/induzido quimicamente , Hemorragia Gastrointestinal/etiologia , Estudos RetrospectivosRESUMO
NEW FINDINGS: What is the central question of this study? Are circulating monocyte markers correlated with their derived macrophage polarization patterns and coronary artery disease severity? What is the main finding and its importance? There was an inverse relationship between circulating CD16+ monocytes (high) and M2 macrophages (low) that marked coronary disease severity, and the differences in polarization of macrophages were seen despite a week of cell culture ex vivo. This study highlights the importance, and potential prognostic implications, of circulating monocyte and descendant macrophage phenotypes in coronary artery disease. ABSTRACT: Monocytes and macrophages are central to atherosclerosis, but how they combine to mark progression of human coronary artery disease (CAD) is unclear. We tested whether patients' monocyte subtypes paired with their derived macrophage profiles were correlated with extent of CAD. Peripheral blood was collected from 40 patients undergoing cardiac catheterization, and patients were categorized as having no significant CAD, single vessel disease or multivessel disease according to the number of affected coronary arteries. Mononuclear cells were measured for the monocyte markers CD14 and CD16 by flow cytometry, and separate monocytes were cultured into macrophages over 7 days and measured for the polarization markers CD86 and CD206. At baseline, patients with a greater CAD burden were older, with higher rates of statin, ß-blocker and antiplatelet drug use, whereas other characteristics were similar across the spectrum of coronary disease. CD16+ (both intermediate and non-classical) monocytes were elevated in patients with single vessel and multivessel disease compared with those without significant CAD (P < 0.05), whereas regulatory M2 macrophages (CD206+ ) were decreased in patients with single vessel and multivessel disease (P < 0.001). An inverse relationship between paired CD16+ monocytes and M2 macrophages marked CAD severity. On multivariable linear regression, CAD severity was associated, along with age and traditional cardiovascular risk factors, with CD16+ monocytes (directly) and M2 macrophages (inversely). Circulating monocytes may influence downstream polarization of lesional macrophages, and these measures of monocyte and macrophage subtypes hold potential as biomarkers in CAD.
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Biomarcadores/metabolismo , Doença da Artéria Coronariana/metabolismo , Macrófagos/metabolismo , Monócitos/metabolismo , Idoso , Antígenos CD/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Primary vascular tumors such as vascular leiomyosarcomas are rare, but exhibit markedly different characteristics than tumors that invade the vasculature from a secondary source. Establishing a diagnosis is essential in determining the appropriate treatment plan, but obtaining a histologic specimen may prove challenging and carry significant risks. Minimally invasive endovascular biopsy techniques can be pivotal in the diagnosis-and thus in the management-of vascular tumors. We present a case of a primary inferior vena cava leiomyosarcoma, not able to be adequately assessed by noninvasive imaging and deemed too risky to be approached with traditional percutaneous biopsy techniques. Accurate diagnosis of such tumors is critical, as the success of surgical resection, although high risk, depends greatly upon the type, location, and extent of malignancy.
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Biópsia por Agulha/métodos , Cateterismo Venoso Central , Leiomiossarcoma/patologia , Neoplasias Vasculares/patologia , Veia Cava Inferior/patologia , Evolução Fatal , Feminino , Humanos , Leiomiossarcoma/diagnóstico por imagem , Leiomiossarcoma/cirurgia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Resultado do Tratamento , Neoplasias Vasculares/diagnóstico por imagem , Neoplasias Vasculares/cirurgia , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/cirurgiaRESUMO
BACKGROUND: With the increasing use of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), computed tomography (CT) remains the standard for annulus sizing. However, 3D transesophageal echocardiography (TEE) has been an alternative in patients with contraindications to CT. We sought to (1) test the feasibility, accuracy, and reproducibility of prototype 3DTEE analysis software (Philips) for aortic annular measurements and (2) compare the new approach to the existing echocardiographic techniques. METHODS: We prospectively studied 52 patients who underwent gated contrast CT, procedural 3DTEE, and TAVR. 3DTEE images were analyzed using novel semi-automated software designed for 3D measurements of the aortic root, which uses multiplanar reconstruction, similar to CT analysis. Aortic annulus measurements included area, perimeter, and diameter calculations from these measurements. The results were compared to CT-derived values. Additionally, 3D echocardiographic measurements (3D planimetry and mitral valve analysis software adapted for the aortic valve) were also compared to the CT reference values. RESULTS: 3DTEE image quality was sufficient in 90% of patients for aortic annulus measurements using the new software, which were in good agreement with CT (r-values: .89-.91) and small (<4%) inter-modality nonsignificant biases. Repeated measurements showed <10% measurements variability. The new 3D analysis was the more accurate and reproducible of the existing echocardiographic techniques. CONCLUSIONS: Novel semi-automated 3DTEE analysis software can accurately measure aortic annulus in patients with severe AS undergoing TAVR, in better agreement with CT than the existing methodology. Accordingly, intra-procedural TEE could potentially replace CT in patients where CT carries significant risk.
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Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/terapia , Valva Aórtica/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Interpretação de Imagem Assistida por Computador/métodos , Software , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Algoritmos , Aorta/diagnóstico por imagem , Aorta/cirurgia , Valva Aórtica/cirurgia , Feminino , Humanos , Aumento da Imagem/métodos , Masculino , Ajuste de Prótese/métodos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoAssuntos
Embolia Pulmonar/terapia , Terapia Trombolítica/normas , Doença Aguda , Administração Oral , Anticoagulantes/administração & dosagem , Antitrombinas/administração & dosagem , Cardiologia/normas , Progressão da Doença , Embolectomia , Europa (Continente) , Humanos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Pneumologia/normas , Recidiva , Medição de Risco , Terapia de Salvação/normas , Sociedades Médicas/normas , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos , Terapia Trombolítica/mortalidade , Tromboembolia Venosa/complicações , Tromboembolia Venosa/terapiaRESUMO
Background: Clinical trials suggest that therapeutic-dose heparin may prevent critical illness and vascular complications due to COVID-19, but knowledge gaps exist regarding the efficacy of therapeutic heparin including its comparative effect relative to intermediate-dose anticoagulation. Objectives: The authors performed 2 complementary secondary analyses of a completed randomized clinical trial: 1) a prespecified per-protocol analysis; and 2) an exploratory dose-based analysis to compare the effect of therapeutic-dose heparin with low- and intermediate-dose heparin. Methods: Patients who received initial anticoagulation dosed consistently with randomization were included. The primary outcome was organ support-free days (OSFDs), a combination of in-hospital death and days free of organ support through day 21. Results: Among 2,860 participants, 1,761 (92.8%) noncritically ill and 857 (89.1%) critically ill patients were treated per-protocol. Among noncritically ill per-protocol patients, the posterior probability that therapeutic-dose heparin improved OSFDs as compared with usual care was 99.3% (median adjusted OR: 1.36; 95% credible interval [CrI]: 1.07-1.74). Therapeutic heparin had a high posterior probability of efficacy relative to both low- (94.6%; adjusted OR: 1.26; 95% CrI: 0.95-1.64) and intermediate- (99.8%; adjusted OR: 1.80; 95% CrI: 1.22-2.62) dose thromboprophylaxis. Among critically ill per-protocol patients, the posterior probability that therapeutic heparin improved outcomes was low. Conclusions: Among noncritically ill patients hospitalized for COVID-19 who were randomized to and initially received therapeutic-dose anticoagulation, heparin, compared with usual care, was associated with improved OSFDs, a combination of in-hospital death and days free of organ support. Therapeutic heparin appeared superior to both low- and intermediate-dose thromboprophylaxis.
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Successful implantation and long-term survival of engineered tissue grafts hinges on adequate vascularization of the implant. Endothelial cells are essential for patterning vascular structures, but they require supportive mural cells such as pericytes/mesenchymal stem cells (MSCs) to generate stable, functional blood vessels. While there is evidence that the angiogenic effect of MSCs is mediated via the secretion of paracrine signals, the identity of these signals is unknown. By utilizing two functionally distinct human MSC clones, we found that so-called "pericytic" MSCs secrete the pro-angiogenic vascular guidance molecule SLIT3, which guides vascular development by directing ROBO4-positive endothelial cells to form networks in engineered tissue. In contrast, "non-pericytic" MSCs exhibit reduced activation of the SLIT3/ROBO4 pathway and do not support vascular networks. Using live cell imaging of organizing 3D vascular networks, we show that siRNA knockdown of SLIT3 in MSCs leads to disorganized clustering of ECs. Knockdown of its receptor ROBO4 in ECs abolishes the generation of functional human blood vessels in an in vivo xenogenic implant. These data suggest that the SLIT3/ROBO4 pathway is required for MSC-guided vascularization in engineered tissues. Heterogeneity of SLIT3 expression may underlie the variable clinical success of MSCs for tissue repair applications.
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Proteínas de Membrana/genética , Neovascularização Fisiológica/genética , Receptores de Superfície Celular/genética , Engenharia Tecidual , Ativação Transcricional , Animais , Comunicação Celular , Movimento Celular , Análise por Conglomerados , Células Endoteliais/metabolismo , Feminino , Perfilação da Expressão Gênica , Regulação da Expressão Gênica no Desenvolvimento , Técnicas de Silenciamento de Genes , Humanos , Proteínas de Membrana/metabolismo , Células-Tronco Mesenquimais/citologia , Células-Tronco Mesenquimais/metabolismo , Camundongos , Pericitos/citologia , Pericitos/metabolismo , Fenótipo , Interferência de RNA , Receptores de Superfície Celular/metabolismo , Transdução de Sinais , Alicerces TeciduaisRESUMO
Background: Patients hospitalized for COVID-19 are at high risk of thrombotic complications and organ failure, and often exhibit severe inflammation, which may contribute to hypercoagulability. Objectives: To determine whether patients hospitalized for COVID-19 experience differing frequencies of thrombotic and organ failure complications and derive variable benefits from therapeutic-dose heparin dependent on the extent of systemic inflammation and whether observed benefit from therapeutic-dose anticoagulation varies depending on the degree of systemic inflammation. Methods: We analyzed data from 1346 patients hospitalized for COVID-19 enrolled in the ATTACC and ACTIV-4a platforms who were randomized to therapeutic-dose heparin or usual care for whom levels of C-reactive protein (CRP) were reported at baseline. Results: Increased CRP was associated with worse patient outcomes, including a >98% posterior probability of increased organ support requirement, hospital length of stay, risk of 28-day mortality, and incidence of major thrombotic events or death (patients with CRP 40-100 mg/L or ≥100 mg/L compared to patients with CRP <40 mg/L). Patients with CRP 40 to 100 mg/L experienced the greatest degree of benefit from treatment with therapeutic doses of unfractionated or low molecular weight heparin compared with usual-care prophylactic doses. This was most significant for an increase in organ support-free days (odds ratio: 1.63; 95% confidence interval, 1.09-2.40; 97.9% posterior probability of beneficial effect), with trends toward benefit for other evaluated outcomes. Conclusion: Moderately ill patients hospitalized for COVID-19 with CRP between 40 mg/L and 100 mg/L derived the greatest benefit from treatment with therapeutic-dose heparin.
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Deep vein thrombosis is a major source of morbidity and mortality worldwide. For acute proximal deep vein thrombosis, catheter-directed thrombolytic therapy is an accepted method for vessel recanalization. Thrombolytic therapy is not without risk, including the potential for hemorrhagic bleeding that increases with lytic dose. Histotripsy is a focused ultrasound therapy that generates bubble clouds spontaneously in tissue at depth. The mechanical activity of histotripsy increases the efficacy of thrombolytic therapy at doses consistent with current pharmacomechanical treatments for venous thrombosis. The objective of this study was to determine the influence of lytic dose on histotripsy-enhanced fibrinolysis. Human whole blood clots formed in vitro were exposed to histotripsy and a thrombolytic agent (recombinant tissue plasminogen activator, rt-PA) in a venous flow model perfused with plasma. Lytic was administered into the clot via an infusion catheter at concentrations ranging from 0 (control) to 4.54 µg/mL (a common clinical dose for catheter-directed thrombolysis). Following treatment, perfusate samples were assayed for markers of fibrinolysis, hemolysis, and intact red blood cells and platelets. Fibrinolysis was equivalent between the common clinical dose of rt-PA (4.54 µg/mL) and rt-PA at a reduction to one-twentieth of the common clinical dose (0.23 µg/mL) when combined with histotripsy. Minimal changes were observed in hemolysis for treatment arms with or without histotripsy, potentially due to clot damage from insertion of the infusion catheter. Likewise, histotripsy did not increase the concentration of red blood cells or platelets in the perfusate following treatment compared to rt-PA alone. At the highest lytic dose, a refined histotripsy exposure scheme was implemented to cover larger areas of the clot. The updated exposure scheme improved clot mass loss and fibrinolysis relative to administration of lytic alone. Overall, the data collected in this study indicate the rt-PA dose can be reduced by more than a factor of ten and still promote fibrinolysis when combined with histotripsy.
Assuntos
Fibrinólise/efeitos dos fármacos , Fibrinolíticos/farmacologia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/farmacologia , Plaquetas/química , Catéteres , Eritrócitos/química , Fibrinolíticos/uso terapêutico , Hemoglobinas/química , Humanos , Técnicas In Vitro , Proteínas Recombinantes/biossíntese , Proteínas Recombinantes/isolamento & purificação , Proteínas Recombinantes/farmacologia , Proteínas Recombinantes/uso terapêutico , Ativador de Plasminogênio Tecidual/genética , Ativador de Plasminogênio Tecidual/metabolismo , Ativador de Plasminogênio Tecidual/uso terapêutico , Trombose Venosa/tratamento farmacológicoAssuntos
Cateterismo Cardíaco/métodos , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Doença da Artéria Coronariana/complicações , Falha de Equipamento , Insuficiência Cardíaca/complicações , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Deep vein thrombosis is a major source of morbidity worldwide. For critical obstructions, catheter-directed thrombolytics are the frontline therapy to achieve vessel recanalization. Techniques that aid lytic therapy are under development to improve treatment efficacy and reduce procedure-related complications. Histotripsy is one such adjuvant under development that relies on focused ultrasound for in situ nucleation of bubble clouds. Prior studies have demonstrated synergistic effects for clot dissolution when histotripsy is combined with lytic therapy. The success of this combination approach is hypothesized to promote thrombolytic efficacy via two mechanisms: erythrocyte fractionation (hemolysis) and increased lytic activity (fibrinolysis). In this study, the contributions of hemolysis and fibrinolysis to clot degradation under histotripsy and a lytic were quantified with measurements of hemoglobin and D-dimer, respectively. A linear regression analysis was used to determine the relationship between hemoglobin, D-dimer, and the overall treatment efficacy (clot mass loss). A similar analysis was conducted to gauge the role of bubble activity, which was assessed with passive cavitation imaging, on hemolysis and fibrinolysis. Tabulation of these data demonstrated hemolysis and fibrinolysis contributed equally to clot mass loss. Furthermore, bubble cloud activity promoted the generation of hemoglobin and D-dimer in equal proportion. These studies indicate a multifactorial process for clot degradation under the action of histotripsy and a lytic therapy.
Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade , Preparações Farmacêuticas , Trombose , Humanos , Imagens de Fantasmas , Trombose/terapiaRESUMO
Venous thromboembolism is a significant source of morbidity and mortality worldwide. Catheter-directed thrombolytics is the primary treatment used to relieve critical obstructions, though its efficacy varies based on the thrombus composition. Non-responsive portions of the specimen often remain in situ, which prohibits mechanistic investigation of lytic resistance or the development of diagnostic indicators for treatment outcomes. In this study, thrombus samples extracted from venous thromboembolism patients were analyzed ex vivo to determine their histological properties, susceptibility to lytic therapy, and imaging characteristics. A wide range of thrombus morphologies were observed, with a dependence on age and etymology of the specimen. Fibrinolytic inhibitors including PAI-1, alpha 2-antiplasmin, and TAFI were present in samples, which may contribute to the response venous thrombi to catheter-directed thrombolytics. Finally, a weak but significant correlation was observed between the response of the sample to lytic drug and its magnetic microstructure assessed with a quantitative MRI sequence. These findings highlight the myriad of changes in venous thrombi that may promote lytic resistance, and imaging metrics that correlate with treatment outcomes.
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Biomarcadores/metabolismo , Técnicas de Imagem por Elasticidade/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Ultrassonografia/métodos , Trombose Venosa/patologia , Fibrinolíticos/administração & dosagem , Humanos , Trombose Venosa/tratamento farmacológico , Trombose Venosa/metabolismoRESUMO
Although primarily known as an ablative modality, histotripsy can increase the efficacy of lytic therapy in a retracted venous clot model. Bubble cloud oscillations are the primary mechanism of action for histotripsy, and the type of bubble activity is dependent on the pulse duration. A retracted human venous clot model was perfused with and without the thrombolytic recombinant tissue plasminogen activator (rt-PA). The clot was exposed to histotripsy pulses of single- or five-cycle duration and peak negative pressures of 0-30 MPa. Bubble activity within the clot was monitored via passive cavitation imaging. The combination of histotripsy and rt-PA was more efficacious than rt-PA alone for single- and five-cycle pulses with peak negative pressures of 25 and 20 MPa, respectively. For both excitation schemes, the detected acoustic emissions correlated with the degree of thrombolytic efficacy. These results indicate that rt-PA and single- or multicycle histotripsy pulses enhance thrombolytic therapy.
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Fibrinolíticos/uso terapêutico , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Terapia por Ultrassom , Adulto , Idoso , Terapia Combinada , Humanos , Técnicas In Vitro , Masculino , Pessoa de Meia-Idade , Imagens de Fantasmas , Terapia por Ultrassom/métodosRESUMO
As a bubble-based ablative therapy, the efficacy of histotripsy has been demonstrated in healthy or acutely diseased models. Chronic conditions associated with stiff tissues may require additional bubble activity prior to histotripsy liquefaction. In this study, histotripsy pulses were generated in agarose phantoms of Young's moduli ranging from 12.3 to 142 kPa, and in vitro clot models with mild and strong platelet-activated retraction. Bubble cloud emissions were tracked with passive cavitation imaging, and the threshold acoustic power associated with phantom liquefaction was extracted with receiver operator characteristic analysis. The power of histotripsy-generated emissions and the degree of liquefaction were tabulated for both clot models. For the agarose phantoms, the acoustic power associated with liquefaction increased with Young's modulus. When grouped based on agarose concentration, only two arms displayed a significant difference in the liquefaction threshold acoustic power (22.1 kPa versus 142 kPa Young's modulus). The bubble cloud dynamics tracked with passive cavitation imaging indicated no strong changes in the bubble dynamics based on the phantom stiffness. For identical histotripsy exposure, the power of acoustic emissions and degree of clot lysis did not vary based on the clot model. Overall, these results indicate that a fixed threshold acoustic power mapped with passive cavitation imaging can be utilized for predicting histotripsy liquefaction over a wide range of tissue stiffness.
Assuntos
Módulo de Elasticidade , Géis/análise , Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Litotripsia/métodos , Microbolhas , Imagens de Fantasmas , Trombose , Acústica , Idoso , Animais , Feminino , Géis/química , Humanos , Processamento de Imagem Assistida por Computador/métodos , Masculino , Pessoa de Meia-Idade , Curva ROC , SuínosRESUMO
BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a resource-intensive tool that provides haemodynamic and respiratory support in patients who have suffered cardiac arrest. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution. METHODS: We performed a retrospective review of patients who received ECPR following cardiac arrest between 2012 and 2018. All medical care-associated charges with ECPR and subsequent hospital admission were recorded. The quality-of-life of survivors was assessed with the Health Utilities Index Mark II. The cost-utility of ECPR was calculated with cost and quality-of-life data. RESULTS: ECPR was used in 32 patients (15/32 in-hospital, 47%) with a median age of 55.0 years (IQR 46.3-63.3 years), 59% male and 66% African American. The median duration of ECPR support was 2.1 days (IQR 0.9-3.8 days). Survival to hospital discharge was 16%. The median score of the Health Utilities Index Mark II at discharge for the survivors was 0.44 (IQR 0.32-0.52). The median operating cost for patients undergoing ECMO was $125,683 per patient (IQR $49,751-$206,341 per patient). The calculated cost-utility for ECPR was $56,156/QALY gained. CONCLUSIONS: The calculated cost-utility is within the threshold considered cost-effective in the United States (<$150,000/QALY gained). These results are comparable to the cost-effectiveness of heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics, affect the cost-utility benefit.
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Reanimação Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea/economia , Custos Hospitalares/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Análise Custo-Benefício , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/economia , Parada Cardíaca Extra-Hospitalar/mortalidade , Anos de Vida Ajustados por Qualidade de Vida , Sistema de Registros , Estudos RetrospectivosRESUMO
A 76-year-old male presented with a submassive pulmonary embolism despite having an inferior vena cava (IVC) filter. Imaging demonstrated pulmonary artery emboli and a deep vein thrombosis in the left common femoral vein. Venography revealed the IVC filter with struts extending into the left and right renal veins. A new IVC filter was deployed below the prior filter. This case demonstrates IVC filter migration complicated by a submassive pulmonary embolism.
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Cateterismo/métodos , Migração de Corpo Estranho/complicações , Embolia Pulmonar/tratamento farmacológico , Veias Renais , Terapia Trombolítica/métodos , Filtros de Veia Cava/efeitos adversos , Idoso , Migração de Corpo Estranho/diagnóstico , Migração de Corpo Estranho/tratamento farmacológico , Humanos , Masculino , Flebografia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: Endothelial progenitor cells (EPCs) that may repair vascular injury are reduced in patients with coronary artery disease (CAD). We reasoned that EPC number and function may be increased by granulocyte colony-stimulating factor (G-CSF) used to mobilize hematopoietic progenitor cells in healthy donors. METHODS AND RESULTS: Sixteen CAD patients had reduced CD34(+)/CD133(+) (0.0224+/-0.0063% versus 0.121+/-0.038% mononuclear cells [MNCs], P<0.01) and CD133(+)/VEGFR-2(+) cells, consistent with EPC phenotype (0.00033+/-0.00015% versus 0.0017+/-0.0006% MNCs, P<0.01), compared with 7 healthy controls. Patients also had fewer clusters of cells in culture, with out-growth consistent with mature endothelial phenotype (2+/-1/well) compared with 16 healthy subjects at high risk (13+/-4/well, P<0.05) or 14 at low risk (22+/-3/well, P<0.001) for CAD. G-CSF 10 microg/kg per day for 5 days increased CD34(+)/CD133(+) cells from 0.5+/-0.2/microL to 59.5+/-10.6/microL and CD133(+)/ VEGFR-2(+) cells from 0.007+/-0.004/microL to 1.9+/-0.6/microL (both P<0.001). Also increased were CD133(+) cells that coexpressed the homing receptor CXCR4 (30.4+/-8.3/microL, P<0.05). Endothelial cell-forming clusters in 10 patients increased to 27+/-9/well after treatment (P<0.05), with a decline to 9+/-4/well at 2 weeks (P=0.06). CONCLUSIONS: Despite reduced EPCs compared with healthy controls, patients with CAD respond to G-CSF with increases in EPC number and homing receptor expression in the circulation and endothelial out-growth in culture. Endothelial progenitor cells (EPCs) are reduced in coronary artery disease. Granulocyte colony-stimulating factor (CSF) administered to patients increased: (1) CD133+/VEGFR-2+ cells consistent with EPC phenotype; (2) CD133+ cells coexpressing the chemokine receptor CXCR4, important for homing of EPCs to ischemic tissue; and (3) endothelial cell-forming clusters in culture. Whether EPCs mobilized into the circulation will be useful for the purpose of initiating vascular growth and myocyte repair in coronary artery disease patients must be tested in clinical trials.
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Doença das Coronárias/terapia , Glicoproteínas/sangue , Fator Estimulador de Colônias de Granulócitos/farmacologia , Mobilização de Células-Tronco Hematopoéticas , Células-Tronco Hematopoéticas , Peptídeos/sangue , Antígeno AC133 , Adulto , Idoso , Animais , Antígenos CD , Antígenos CD34/sangue , Biomarcadores , Diferenciação Celular , Linhagem da Célula , Células Cultivadas/efeitos dos fármacos , Ensaio de Unidades Formadoras de Colônias , Doença das Coronárias/sangue , Células Endoteliais/química , Células Endoteliais/citologia , Endotélio Vascular/patologia , Feminino , Filgrastim , Células-Tronco Hematopoéticas/química , Humanos , Masculino , Camundongos , Pessoa de Meia-Idade , Receptores CXCR4/análise , Proteínas Recombinantes , Fatores de Risco , Receptor 2 de Fatores de Crescimento do Endotélio Vascular/sangueRESUMO
BACKGROUND: Patent foramen ovale (PFO) has been linked to cryptogenic stroke, and closure has been reported to improve clinical outcomes. However, there are no clear guidelines to direct device sizing. This study sought to use patient characteristics and echocardiographic findings to create a prediction score for device sizing. METHODS: This was a retrospective review of patients undergoing percutaneous PFO closure at our institution between July 2010 and December 2014. Demographic and clinical characteristics were recorded, and all pre- and intraprocedural echocardiography results were evaluated. RESULTS: Thirty-six patients underwent percutaneous PFO closure during the study period. All procedures were performed using an Amplatzer Septal Occluder "Cribriform" (ASOC) device in one of three disc diameters: 25, 30, or 35 mm. Closure was indicated for cryptogenic stroke/transient ischemic attack in 75% of cases. Every case (100%) was successful with durable shunt correction at the 6-month follow-up without complications of erosion or device embolization. The presence of atrial septal aneurysm (ASA) (p = 0.027) and PFO tunnel length >10 mm (p = 0.038) were independently associated with increased device size. A scoring system of 1 point for male sex, 1 point for ASA, and 1 point for PFO tunnel >10 mm long was associated with the size of closure device implanted (p = 0.006). CONCLUSIONS: A simple scoring system may be used to select an optimally sized device for percutaneous PFO closure using the ASOC device.
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A variety of interventional management approaches exist for the treatment of acute pulmonary embolism (PE). However, when PE is accompanied by residual right heart thrombus, the best therapeutic options are less clear. We describe a novel combined technique of percutaneous aspiration of unstable right atrial thrombus followed by ultrasound-directed thrombolysis of massive PE.