High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study.

OBJECTIVES: The study examined the effect of isovolumic high-volume hemofiltration (HF) alone or combined with mild hypothermia (HT) on survival after out-of-hospital cardiac arrest (OHCA) with initial ventricular fibrillation or asystole. BACKGROUND: Global inflammation in response to whole-body ischemia-reperfusion is common after OHCA and may worsen the overall prognosis. METHODS: Sixty-one patients admitted between May 2000 and March 2002 in the intensive care units of two hospitals in France were randomized to one of three groups: control, HF (200 ml/kg/h over 8 h) or HF+HT (32 degrees C for 24 h) induced by cooling the HF substitution fluid. Standard supportive care was provided in all three groups. The primary end point was survival with a follow-up time of six months. The effect of HF on death by intractable shock was the secondary end point. RESULTS: The six-month survival curves of the three groups were significantly different, with better survival in the HF group (p = 0.026) and in the HF+HT group (p = 0.018). After adjustment on baseline characteristics of cardiac arrest, HF (with or without HT) was associated with improved survival (logistic regression odds ratio, 4.4; 95% confidence interval [CI], 1.1 to 16.6). Compared to control group, the relative risk of death by intractable shock was 0.29 (95% CI, 0.09 to 0.91) in the HF+HT group and 0.21 (95% CI, 0.05 to 0.85) in the HF group. CONCLUSIONS: The HF may improve the overall prognosis after resuscitation from OHCA. Combination of HF with mild HT is feasible and should be evaluated in larger trials.

Characterization of vulnerable nonstenotic plaque with 16-slice computed tomography compared with intravascular ultrasound.

We compared 16-slice computed tomography with intravascular ultrasound in the detection of unstable component characteristics of nonstenotic plaque responsible for acute coronary syndrome. Computed tomography accurately assessed plaque eccentricity, calcification, and remodeling, and intraplaque hypodensity correlated with intravascular ultrasound echolucent area.

Coronary plaque burden detected by multislice computed tomography after acute myocardial infarction with near-normal coronary arteries by angiography.

Nonsignificant coronary artery plaque rupture or erosion may be the origin of acute myocardial infarction (AMI). The aim of our study was to assess the ability of multislice computed tomography (MSCT) to detect coronary plaques responsible for near normal coronary angiography AMI. Eight patients with presentation of AMI and no significant coronary narrowing by angiography were enrolled. Two groups were defined: (1) true AMI and (2) myocarditis. MSCT was able to detect nonsignificant coronary soft plaques responsible for AMI and has provided information on plaque volume, eccentricity, and density. In patients with myocarditis, there was no evidence of plaque.

Use of a deflectable tip catheter to facilitate complex interventions beyond insertion of coronary bypass grafts: three case reports.

We present three patients with angulated ostial lesions beyond the insertion point of coronary artery bypass grafts. Use of the Venture Catheter, a deflectable tip 3.5F wire control catheter, facilitated successful percutaneous coronary intervention after prolonged, unsuccessful attempts at conventional guidewire passage.

Prevention of arterial spasm during percutaneous coronary interventions through radial artery: the SPASM study.

AIMS: Radial artery spasm remains the major limitation of transradial approach for percutaneous coronary interventions. The aim of our study was to evaluate the efficacy of vasodilators in the prevention of radial artery spasm during percutaneous coronary interventions. METHODS AND RESULTS: 1,219 patients were consecutively randomized to receive placebo (n = 198), molsidomine 1 mg (n = 203), verapamil 2.5 mg (n = 409), 5 mg (n = 203) or verapamil 2.5 mg and molsidomine 1 mg (n = 206). All drugs were administered through the arterial sheath. The primary end point was the occurrence of a radial artery spasm defined by the operator as severe limitation of the catheter movement, with or without angiographic confirmation. Main characteristics including age, sex, wrist and arterial sheath diameters and procedure duration were identical across the groups. The rate of radial artery spasm was lowest in patients receiving verapamil and molsidomine (4.9%), compared to verapamil 2.5 mg or 5 mg (8.3 and 7.9%), or molsidomine 1 mg (13.3%); and placebo (22.2%) (P < 0.0001). CONCLUSION: Radial artery spasm during transradial percutaneous interventions was effectively prevented by the administration of vasodilators. The combination of verapamil 2.5 mg and molsidomine 1 mg provided the strongest relative risk reduction of spasm compared to placebo and should therefore be recommended during percutaneous coronary interventions through the radial approach.

Direct stenting with 3000 i.u. heparin.

In order to reduce vascular complications, the authors assessed safety and feasability of a new percutaneous transluminal coronary angioplasty (PTCA) strategy consisting of direct stenting with 3000 i.u. heparin and immediate sheath removal. Predicting factors of vascular complications during PTCA include heparin dosages, sheath dwell time and use of anti-glycoprotein (GP) IIb/IIIa. A simplified PTCA with direct stenting technique may allow the use of very low doses of heparin without anti-GPIIb/IIIa in selected cases. From April 1999 to April 2000 all patients who underwent PTCA in the authors' center were screened. Exclusion criteria comprised a contraindication for direct stenting, primary PTCA for acute myocardial infarction (MI) and a TIMI (thrombolysis in myocardial infarction) grade zero flow. All other patients were included. They received 3000 i.u. heparin before direct stenting whatever their current anticoagulation and their weight. The sheath was immediately removed using manual compression. Out of 716 consecutive PTCA patients, 171 (24%) were enrolled in the study (198 sites). Complete protocol was achieved in 150 patients (88%). Activated clotting time during the procedure was 179 +/- 32 seconds. No subacute thrombosis or creatine kinase elevation was observed before discharge. Only two uncomplicated groin hematomas and two false aneurysms (one surgical repair) were noted. This study shows that direct stenting with 3000 iu heparin is safe. Immediate sheath removal can be performed with a low rate of major vascular complications.