Agreement among observers in the assignment of TransAtlantic Inter-Society Consensus classification and runoff score.

OBJECTIVE: Productive communication among clinical practitioners is essential if recommendations regarding practice are to exist. The durability of vascular procedures is often influenced by factors such as lesion classification and runoff quality. It is the purpose of this article to determine how reproducible these measures are in the hands of various specialists who deal extensively with peripheral arterial disease. METHODS: The peripheral arteriograms of 100 patients undergoing percutaneous intervention were distributed to six specialists (three vascular surgeons, two interventional radiologists, and one interventional cardiologist). Each was provided with the reference document describing TASC II classification, Society for Vascular Surgery (SVS) runoff score, and simplified runoff score. With no further instruction, each individual was asked to assign each angiogram a TASC II class, SVS runoff score, and a simplified runoff score. Comparisons between the scores assigned were made using kappa statistic. RESULTS: When using the simplified runoff score for grading peripheral arterial disease, there was excellent correlation among readers (k = 0.81; P = .001), even across different specialties. When using TASC II class to grade lesions, there was a greater degree of variation when compared with the simplified runoff score (k = 0.44; P < .05). Finally, there was poor correlation between readers when using the SVS runoff score (k = 0.10; P < .05) and the modified SVS runoff score (k = 0.26; P = .001). CONCLUSIONS: Descriptors of clinical disease severity are not universally reproducible. The simplified runoff score is reproducible when interpreted by multiple readers across different specialties and can be used without further modification. The TASC II classification may need minor alterations in description to obtain good correlation among readers. Before the SVS runoff score can be universally adapted, it will need to be described in much better detail or significantly modified.

Intrinsic frequency method for instantaneous assessment of left ventricular-arterial coupling after transcatheter aortic valve replacement.

BACKGROUND: Aortic stenosis (AS) is the most common cause for valve replacement in the United States. The pathophysiology of AS involves obstruction to the left ventricular (LV) outflow and reduced arterial compliance. The intrinsic frequency (IF) method is a system-based approach for hemodynamic monitoring of the LV-arterial system and involves determination of ω1 and ω2, which represent the dynamics of LV systolic and vascular function, respectively. Total frequency variation of the systemic circulation is the difference between these IFs (Δω = ω1- ω2). OBJECTIVE: Our goal in this study was to investigate whether Δω, obtained from the ascending aortic pressure waveform, can be indicative of LV-arterial coupling after transcatheter aortic valve replacement (TAVR). APPROACH: Thirty patients undergoing elective TAVR for severe, symptomatic AS were included. We applied the IF method to assess the immediate effects of TAVR on LV-arterial coupling. MAIN RESULTS: Mean age was 86 ± 4 years, 50% were male with a mean aortic valve area of 0.7 cm2 and mean ejection fraction (EF) of 59 ± 7%. The results showed a significant decrease in Δω (47.6 to 9.5 bpm, p < 0.00001) and a significant increase in ω2 (51.9 to 84.6 bpm, p < 0.00001) immediately post TAVR. SIGNIFICANCE: These preliminary findings indicate that the IF method can be used to evaluate improvements in LV hemodynamics immediately following TAVR. Use of the IF method may have implications for patients undergoing TAVR with impaired LV systolic function.

Intravenous milrinone infusion improves congestive heart failure caused by diastolic dysfunction: a brief case series.

Although there have been significant advances in the medical treatment of heart failure patients with impaired systolic function, very little is known about the diagnosis and treatment of diastolic dysfunction. We report the cases of 3 patients in New York Heart Association functional class IV who had echocardiographically documented diastolic dysfunction as the main cause of heart failure. All 3 patients received medical therapy with long-term milrinone infusion.

Prehospital 12-Lead Electrocardiogram within 60 Minutes Differentiates Proximal versus Nonproximal Left Anterior Descending Artery Myocardial Infarction.

INTRODUCTION: Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions. METHODS: In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset. RESULTS: In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups. CONCLUSION: The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.

Initial report of percutaneous right ventricular assist for right ventricular shock secondary to right ventricular infarction.

A 57-year-old female suffered an acute inferior ST segment elevation myocardial infarction. The patient failed thrombolysis and was urgently transferred for rescue percutaneous coronary intervention of the right coronary artery. She decompensated after reperfusion of the occluded RCA and developed cardiogenic shock from severe right heart failure refractory to IABP support and maximal pressors. A percutaneous right ventricular assist device was successfully implanted, which improved mean arterial pressure to a viable range and allowed withdrawal of inotropic medications. Right ventricular failure after infarction remains difficult to manage and has a high mortality. Intraaortic balloon pump and LVAD support have not proven beneficial in cardiogenic shock secondary to RV infarction. This is a report of the first insertion of a percutaneous right ventricular assist device for right ventricular support in a human. Further evaluation is warranted to evaluate the potential benefits of such a device as well as optimal timing of initiation of RV support.

Difficult retrieval of the EPI Filterwire with a 5 French FR4 coronary catheter following carotid stenting.

Carotid angioplasty and stenting with an embolic protection device is emerging as a reasonable alternative to carotid endarterectomy in high-risk patients. The deployment and retrieval of these devices, however, can be problematic. We describe a case where a 5 Fr FR4 coronary catheter was used to retrieve an EPI Filterwire device following carotid stenting.

Risk of bleeding complications is not increased in patients undergoing rescue versus primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: Concern for major bleeding complications (MBC) may lead to withholding of anticoagulation and fibrinolytic therapy in preparation for primary percutaneous coronary intervention (PCI), potentially resulting in unacceptable delays in achieving reperfusion. OBJECTIVES: The primary objective of this study was to evaluate MBC associated with primary and rescue PCI and how timing to revascularization affects this variable. METHODS: We evaluated 659 consecutive patients presenting within 24 hours of an acute ST elevation myocardial infarctions (MI). One hundred and eighty-three patients presented for rescue PCI and 476 for primary PCI. Eighty-seven rescue PCI patients were treated within 6 hours of their first dose of fibrinolytic. Demographics, procedural variables, outcomes, and major adverse cardiovascular events (MACE) were compared between the primary and rescue PCI groups and between early and late presenters in the rescue PCI group. RESULTS: We observed that the incidence of MBC was 8% in patients undergoing rescue PCI and 6% in primary PCI (P=0.35). There were no significant differences in bleeding associated with GP IIb/IIIa receptor antagonist use, procedural success, or MACE. Similarly, in patients presenting for early or late rescue PCI there was no significant difference in MBC, procedural success, or MACE. CONCLUSIONS: We concluded that early or late rescue PCI and primary PCI have similar rates of MBC and overall in-hospital outcomes for patients presenting within 24 hours of acute MI. Delaying the timing of a rapid reperfusion strategy in an effort to decrease the incidence of MBC complications is generally not justified.

The level I cardiovascular center: is it time?

There is no uniform approach to treating the 1.5 million US citizens who have an acute myocardial infarction (AMI) each year. This contrasts with the trauma system developed to efficiently triage and treat the critically injured accident victim. Only two thirds of patients with ST-segment elevation AMI in the United States are treated with thrombolytic therapy or primary angioplasty (percutaneous coronary intervention [PCI]) which can reduce the 30-day mortality rate from approximately 15% to 6%-10%. The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial demonstrated that AMI patients who received prehospital thrombolytic therapy and were brought to the nearest receiving hospital experienced a 32-minute reduction in the time to treatment and time to ST-elevation resolution compared with those treated at their time of hospital arrival. This expedited therapy was associated with a low in hospital mortality rate (4.7%). The potential benefit of facilitated PCI with partial-dose thrombolysis and abciximab administration was demonstrated by the Strategies for Patency Enhancement in the Emergency Department (SPEED) investigators who found that double bolus recombinant plasminogen activator (reteplase) (5 + 5 megaunits) and abciximab with the addition of early PCI, resulted in a final infarct-related artery TIMI 3 flow rate of 86% compared with 77% with combination therapy alone. The Primary Angioplasty in Acute Myocardial Infarction (PAMI) investigators have shown that patients admitted with infarct-related artery TIMI 3 flow at the time of primary PCI had less than a 1% 6-month mortality. Treating AMI patients with prehospital, partial dose thrombolysis followed by immediate transport to a Level I cardiovascular center (bypassing the closest hospital if necessary) for facilitated infarct-related artery PCI has the potential to reduce the mortality in ST-elevation AMI patients from 6%-10% to less than 4% which could translate into saving approximately 500 lives per day in the United States. It is time to validate this strategy with a randomized clinical trial, the Prehospital Administration of Thrombolytic Therapy With Urgent Culprit Artery Revascularization trial (PATCAR).

Early and aggressive treatment of patients with acute ST segment elevation and non-ST segment elevation myocardial infarction leads to improved clinical outcomes.

Acute myocardial infarction remains a significant burden to our society. Despite being the number 1 cause of mortality, there remains no uniform approach to treatment, which is unlike that of the triage and care of trauma victims. It is now well documented that acute reperfusion therapy has a profound benefit; however, many current strategies take too long to be performed and thus those potential benefits are often reduced. The emergence of prehospital treatment as a means to reducing time to reperfusion provides a new avenue for earlier therapy. With a coordinated aggressive treatment strategy and the identification of primary cardiovascular centers dedicated to the treatment of ST segment elevation myocardial infarctions (STEMI), we believe the mortality of an STEMI can be significantly reduced. Similarly, the treatment of non-ST segment elevation myocardial infarction has shifted to an aggressive approach. Although thrombolytic therapy is not indicated, the use of glycoprotein IIb/IIIa antagonists, as well as early interventional revascularization, is the current preferred treatment strategy. We review important current trials that shape the practice of treatment as well as introduce a novel concept of combined prehospital administration of thrombolytics with urgent culprit artery revascularization.

The update on the rationale, use and selection of beta-blockers in heart failure.

PURPOSE OF REVIEW: The purpose of this review was to describe important developments in the selection of beta-blockers in heart failure. RECENT FINDINGS: The superiority of carvedilol over metoprolol tartrate in one clinical trial is demonstrated, and multiple studies investigated the potential mechanisms of benefit. Current practice patterns still demonstrate the importance of understanding barriers to the effective use of beta-blocking agents. SUMMARY: There are continued refinements in the choice of beta-blockers in heart failure, but clearly an important remaining challenge is to modify health care delivery in an effort to maximize adherence to guidelines.