Ultrasound-guided thrombin-gelatin injection is effective for the treatment of iatrogenic femoral artery pseudoaneurysms: initial results.

OBJECTIVES: To describe the technique of ultrasound (US)-guided percutaneous thrombin-gelatin injection for the treatment of femoral artery pseudoaneurysms (FAPs). BACKGROUND: FAPs are a possible complication from percutaneous angiographic procedures. US-guided thrombin injection is currently the preferential therapeutic option, limited by a low risk of potentially catastrophic femoral thrombosis; transluminal injection of collagen is another effective and safe option, although a more invasive one; surgical repair is associated with significant comorbidity. We hypothesized that US-guided combined thrombin and gelatin injection (UG-TGI) would also be effective while minimizing the risk of limb thrombosis. METHODS: Review of the results, complications and length of hospital admission after the injection into the FAP sac of combined human-origin thrombin and bovine-origin gelatin matrix (FloSeal(®), Baxter), under direct US-guidance. RESULTS: We treated 13 patients (mean age 64 ± 9.46 years, 38% male), who developed a FAP following a percutaneous procedure: isolated coronariography in five (38%); angioplasty in four (31%); other cardiac procedures in four (31%). Immediate success was obtained in all (100%) patients, assessed by US; no allergic reactions, local infection, or embolic events occurred on 30-day follow-up. Median (interquartile range) admission time after the UG-TGI was 2 days (1.25-2.0); median time of total admission was 8 days (6.5-16.25). CONCLUSIONS: In this small study, UG-TGI for the treatment of FAP was feasible and had short-term effectiveness, without a learning curve effect. Despite the need for further experience, a trial comparing different therapies for FAP should include this procedure.

[Diagnosis, prevention and treatment of cardiac allograft vasculopathy]. / Diagnóstico, prevenção e tratamento da doença vascular do aloenxerto.

The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research.

Resting heart rate is a powerful predictor of arrhythmic events in patients with dilated cardiomyopathy and implantable cardioverter-defibrillator.

UNLABELLED: Patients with dilated cardiomyopathy and implantable cardioverter-defibrillator (ICD) are a high-risk group for arrhythmias. They regularly undergo cardiopulmonary exercise testing (CPET) to assess cardiac reserve and to guide clinical decisions or therapeutic adjustments. Data from previous studies demonstrate that prognosis in patients with heart failure (HF) worsens with the presence of appropriate shocks. OBJECTIVE: The purpose of this study was to evaluate the value of CPET parameters to predict shocks and other arrhythmic events in HF patients with ICD, in order to identify a high-risk group for arrhythmias. METHODS: This was a prospective single-center registry of 61 consecutive patients (mean age 55 +/- 15 years, 18% female), with dilated cardiomyopathy (ischemic etiology in 57%) and ICD, who underwent symptom-limited maximal CPET six months or less before device implantation. Minimum follow-up was 180 days. The primary endpoint was appropriate shock and the composite endpoint was appropriate shock and/or ventricular fibrillation (VF) and/or sustained ventricular tachycardia (VT), which were then correlated with hemodynamic variables (heart rate and blood pressure) and CPET parameters. RESULTS: During a mean follow-up of 27 months, eight patients died (13%), two of them from arrhythmic cause (3.3%), and 16 (26%) patients received at least one appropriate ICD shock, eight (13%) due to VF. Sustained VT was recorded in 23 patients (38%) and nonsustained VT in 42 patients (69%). CPET showed that the group with the primary end point had lower peak VO2, anaerobic threshold and chronotropic reserve. On multivariate analysis, resting heart rate was the only independent predictor of appropriate shock (HR 1.06; 95% CI 1.01-1.10; p = 0.025). Univariate analysis identified peak VO2, anaerobic threshold, VE/VCO2 slope, resting heart rate and heart rate decrease during the first minute of recovery, and systolic blood pressure during exercise as predictive of the composite endpoint (shock/VF/sustained VT). Multivariate analysis identified resting heart rate and peak VO2 as independent predictors, with HR 1.04; 95% CI 1.00-1.09 (p = 0.050) and HR 0.88; 95% CI 0.78-0.98 (p = 0.026), respectively. The best cut-off for resting heart rate to predict the composite and primary endpoints was > 76 bpm (area under the ROC curve: 0.67; 95% CI 0.53-0.78 and 0.65; 95% CI 0.51-0.76, respectively). CONCLUSION: Resting heart rate and peak VO2 were identified in multivariate analysis as good predictors of arrhythmic events and resting heart rate was the only independent predictor of appropriate shock in HF patients with ICD. Both advanced stage heart failure and sympathetic overdrive may be associated with the development of malignant arrhythmias.

Myocardial revascularization reverses adverse outcome in non-ST-elevation acute coronary syndromes complicated by heart failure.

BACKGROUND: Congestive heart failure (CHF) has a strong negative prognostic impact in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). The purpose of this study was to establish the effect of myocardial revascularization on prognosis in this setting. METHODS: We retrospectively studied 648 patients admitted with NSTE-ACS and not presenting cardiogenic shock. The effect of coronary revascularization on the outcome of patients with and without CHF was assessed using a propensity score-adjusted regression model. RESULTS: Congestive heart failure was present in 89 patients (14.5%) on hospital admission. During the index hospitalization, 426 patients received myocardial revascularization, through percutaneous coronary intervention (PCI) in 321 cases, and coronary artery bypass grafting (CABG) in 105. In a 6-month follow-up, 38 patients (6.2%) died and 42 (6.8%) experienced non-fatal myocardial infarction (MI). CHF was an independent predictor of both 6-month mortality (adjusted HR 3.6; 95% CI 1.86-6.95; p < 0.001) and 6-month death/(re-)MI (adjusted HR 2.1; 95% CI 1.3-3.5; p = 0.003). Revascularization significantly influenced the prognosis of patients presenting CHF (adjusted HR 0.31; 95% CI 0.13-0.73; p = 0.008), but not of those without CHF (adjusted HR 1.37; 95% CI 0.65-2.89; p = 0.4). A significant interaction was found between revascularization and the prognostic impact of CHF at admission (p = 0.021 for the interaction). CONCLUSIONS: In patients with NSTE-ACS, clinical manifestations of CHF constitute a strong predictor of adverse medium-term outcome that may be significantly modified by myocardial revascularization.

Subcutaneous ICD implantation.

An 18-year-old patient, with hypertrophic cardiomyopathy and an implantable cardioverter defibrillator for 6 years, was admitted with inappropriate shocks as a consequence of a lead fracture (Sprint Quattro, Medtronic). The device was explanted and replaced with a new subcutaneous defibrillator (Cameron SQ-RX), without complications. This was the first time that a subcutaneous cardioverter defibrillator had been used in the Iberian Peninsula. The new implantable defibrillator, with subcutaneous lead and generator, can lower the risk of complications, including lead fracture or infection. Furthermore, this device has good rhythm diagnostic performance and therapeutic efficacy. Following the case report, we present a brief review of the new defibrillator with subcutaneous implantation.

The value of routine intracoronary ultrasound to assess coronary artery disease in cardiac allograft recipients.

UNLABELLED: Cardiac allograft vasculopathy is the main cause of morbidity and mortality after cardiac transplantation. Intravascular ultrasound (IVUS) is a sensitive imaging technique that provides detailed quantification of coronary atherosclerosis burden and could be a complement to routine angiography. AIM: To determine the value of IVUS for detecting silent atherosclerotic disease in cardiac allograft recipients. METHODS: The study cohort consisted of 40 consecutive patients (mean age 55 +/- 11 years, 25% female) who underwent left anterior descending coronary artery IVUS (Volcano Therapeutics, Inc.) examination after transplantation. None of the patients had suspected or documented ischemia. Cardiac transplantation was due to ischemic cardiomyopathy in 30% (12 patients). Coronary artery disease (CAD) was defined as the presence of > or = 30% stenosis of vessel diameter (QCA analysis - Siemens CASS) on angiography and atherosclerotic lesions causing > or = 30% stenosis of vessel area by IVUS. The angiographic definition of significant CAD lesions was > or = 50% stenosis of vessel diameter, and by IVUS a minimum cross-sectional area of < or = 4 mm2. RESULTS: CAD was identified in 20% (8 patients) by angiography and in 55% (22 patients) by IVUS (p = 0.003). Significant CAD was detected in 15% (6 patients) by angiography and in 7.5% (3 patients) by IVUS (p = 0.3). CONCLUSION: The use of IVUS on routine screening coronary angiography detects a higher prevalence of early atherosclerotic disease than normal angiography, which should lead to implementation of preventive strategies to control disease progression. IVUS was no more sensitive than angiography in detecting severe coronary stenosis. IVUS should be used as a standard imaging technique together with routine coronary angiography to assess atherosclerosis burden in cardiac allograft recipients.

[Circumferential pulmonary vein isolation with the cryoballoon technique]. / Isolamento circunferencial das veias pulmonares com a técnica do criobalão.

We present a clinical case on cryoballoon ablation of paroxysmal atrial fibrillation. This is a report of the first case performed at our center using this new technology.

Lipomatous hypertrophy of the interatrial septum: report of two cases where histological examination and surgical intervention were unavoidable.

Lipomatous hypertrophy of the interatrial septum (LHIS) is an increasingly recognized heart condition characterized by fatty deposits in the interatrial septum with sparing of the fossa ovalis. Its distinctive characteristic features by imaging techniques, benign nature, and the fact that most patients remain asymptomatic, has limited the need for histological confirmation and operative intervention in most cases. In this report, we describe two cases of LHIS where cardiac surgical intervention was indispensable: in the first patient, due to the presence of an additional left atrial tumour found out as mixoma and in the second, to relief a superior vena cava obstruction together with bypass grafts for severe coronary artery disease. Histological samples of the interatrial septal lesion were obtained in both cases either because of uncertainty of the diagnosis (Case 1) or to confirm the diagnosis (Case 2).

"Mushroom cloud": a giant left ventricular pseudoaneurysm after a myocardial infarction due to myocardial bridging--a case report.

Left ventricular pseudoaneurysm is an uncommon complication after transmural myocardial infarction, occurring when a free wall rupture is contained by adhesions of the overlying pericardium preventing acute tamponade. In this report, an unusual case of a 61 year-old male with a giant apical left ventricular pseudoaneurysm after an unnoticed myocardial infarction is presented. On coronary angiogram myocardial bridging of the distal left anterior descending artery was judged to be the infarct related lesion. The echocardiographic diagnosis allowed for a timely surgical intervention which resulted in the patient's full recovery.

Inferior and inferior-lateral location of left ventricular dyssynergy after myocardial infarction begets ischemic mitral regurgitation.

INTRODUCTION: Ischemic mitral regurgitation (IMR) after myocardial infarction (MI) results from changes in left ventricular geometry, which may involve the entire ventricular cavity (global remodeling) or predominantly affect the infarct zone (regional remodeling). The relative importance of these two distinct but not mutually exclusive mechanisms in generating IMR has been a matter of debate. The aim of our study was to assess the relative contribution of global versus inferior and inferior-lateral left ventricular dyssynergy in the development of significant IMR after MI. METHODS: We retrospectively studied 40 consecutive patients (24 male, age 68 +/- 11 years) with previous MI and significant IMR evaluated by Doppler study. This group was compared with a control group of 40 consecutive patients (38 male, age 64 +/- 11 years) with previous MI but no significant IMR. Echocardiographic assessment of ventricular volumes and global and regional wall motion indices was performed in both groups. RESULTS: A higher proportion of female patients was found in the group with IMR. There were no significant differences in other demographic or cardiovascular characteristics and risk factors. Left ventricular ejection fraction was reduced in both groups, but was significantly lower in the group with IMR (34 +/- 8% vs. 39 +/- 9%, p = 0.024). Although end-diastolic volumes and global wall motion scores were similar in the two groups, different patterns of regional dyssynergy were found. The degree of inferior and inferior-lateral regional dyssynergy was the main determinant of significant IMR. CONCLUSIONS: Inferior and inferior-lateral left ventricular dyssynergy appears to be more important than global systolic dysfunction in the development of significant ischemic mitral regurgitation. Closer clinical and echocardiographic follow-up is warranted in post-MI patients presenting dyssynergy in this location.

Femoral stenosis due to a collagen closure device treated percutaneously by peripheral stenting.

Late complications from vascular closure devices, such as puncture site stenosis, are not well documented. They may be of clinical significance and probably share the same mechanism that underlies intra-coronary stent restenosis. Thus, treatment approaches based on balloon angioplasty alone may not be sufficient, and the use of stents (when possible) is safe and effective in this setting. We describe the case of a 60-year-old patient with a 90% stenosis of the femoral artery, which CT angiography strongly suggested to be secondary to previous implantation of a closure device.

Diaphragmatic myopotential oversensing in pacemaker-dependent patients with CRT-D devices.

AIMS: To evaluate the incidence and clinical significance of diaphragmatic myopotential (dMP) oversensing in pacemaker (PM)-dependent patients with CRT-Ds. METHODS AND RESULTS: We retrospectively evaluated patients with CRT-Ds implanted at our institution between January 2000 and August 2006. PM-dependent patients were identified, and the incidence of inappropriate detections due to dMP oversensing and their possible clinical implications (inappropriate therapies, syncope, and death of any cause) were evaluated. CRT-Ds were implanted in 122 patients, 37 were or became PM dependent. During a mean follow-up of 22 +/- 17 months, 7(18.9%) PM-dependent patients revealed inappropriate detections due to dMP oversensing. All oversensing episodes occurred in CRT-Ds with automatic gain control (AGC) sensing and integrated bipolar (IBP) leads in the RV apex. These detections led to inappropriate shocks in 2(5.4%) patients and syncope in 1(2.7%). Five (13.5%) patients died. CONCLUSION: dMP oversensing in PM-dependent patients with CRT-Ds is an important problem, particularly in CRT-Ds with AGC sensing and IBP leads, with over 20% of patients with these devices revealing inappropriate detections. The clinical impact of dMP oversensing is less marked but relevant, with both inappropriate therapies and syncope occurring in this small group of 37 patients and the possibility of related deaths.

Subacute left ventricle free wall rupture after acute myocardial infarction: awareness of the clinical signs and early use of echocardiography may be life-saving.

Left ventricular free wall rupture (LVFWR) is a fearful complication of acute myocardial infarction in which a swift diagnosis and emergency surgery can be crucial for successful treatment. Because a significant number of cases occur subacutely, clinicians should be aware of the risk factors, clinical features and diagnostic criteria of this complication. We report the case of a 69 year-old man in whom a subacute left ventricular free wall rupture (LVFWR) was diagnosed 7 days after an inferior myocardial infarction with late reperfusion therapy. An asymptomatic 3 to 5 mm saddle-shaped ST-segment elevation in anterior and lateral leads, detected on a routine ECG, led to an urgent bedside echocardiogram which showed basal inferior-wall akinesis, a small echodense pericardial effusion and a canalicular tract from endo to pericardium, along the interface between the necrotic and normal contracting myocardium, trough which power-Doppler examination suggested blood crossing the myocardial wall. A cardiac MRI further reinforced the possibility of contained LVFWR and a surgical procedure was undertaken, confirming the diagnosis and allowing the successful repair of the myocardial tear. This case illustrates that subacute LVFWR provides an opportunity for intervention. Recognition of the diversity of presentation and prompt use of echocardiography may be life-saving.

Serologic markers for cytomegalovirus in acute coronary syndromes.

BACKGROUND: Several studies relate cytomegalovirus (CMV) infection to the development of atherosclerosis. Its influence in triggering acute coronary syndromes (ACS) is not known. OBJECTIVES: We set out to identify a relationship between CMV infection, occurrence of ACS and prognosis. METHODS: Serologic markers (IgM and IgG) for CMV were tested prospectively at admission and at 30 days, in patients (pts) admitted to our CCU for ACS. Serologic markers for CMV were also tested in a group of pts with stable coronary artery disease admitted for elective coronary angiography. A greater than two-fold elevation of IgG titer at 30 days was defined as reactivation/reinfection. At 30 days and six months, the composite endpoint of death, myocardial (re)infarction and re-admission for unstable angina was evaluated. RESULTS: There were 60 pts with ACS in the study group (age 63 +/- 10 years, 75% male) and 31 pts in the control group (age 64 +/- 10 years, 71% male). On admission, 95% of the pts with ACS and 81% in the control group presented a positive IgG (p = 0.029). In the study group, at 30 days, the only pt with a 3-fold titer elevation had an endpoint. The percentage was 17% for the group with a > or = 2- and < 3-fold elevation and 11% in the group without reactivation (p = 0.034). At six months, 50% of the patients with a greater than 2-fold titer elevation and 15% of the remaining patients had an endpoint (p = 0.017). In the control group, at 30 days, 3 pts (10%) had a significant elevation in IgG titer, > or = 2- and < 3-fold, without endpoint. CONCLUSIONS: In pts with ACS, we found a higher prevalence of serologic markers for CMV than in pts with stable coronary disease. An elevation in IgG titer for CMV was associated with a worse outcome at 30 days and six months.

Safety evaluation of the use of femural percutaneous closure systems with simultaneous use of abciximab.

INTRODUCTION: The growing use of abciximab during coronary angioplasty, with 12 hours of intravenous perfusion, prolongs hospital stay and increases the risk of hemorrhage after sheath removal at the puncture site. Femoral percutaneous closure devices can reduce immobilization time, but their safety in the presence of abciximab in respect to hemorrhage has not been clearly determined. OBJECTIVES: To evaluate the safety and efficacy of the Perclose system in patients undergoing angioplasty with abciximab. POPULATION AND METHODS: The Perclose system was used in 79 patients undergoing angioplasty, with abciximab in 31 patients (58.6 +/- 12.2 years, 90% male, p = NS)--Group 1, and 48 pts without abciximab (61.8 +/- 10.9 years, 79% male, p = NS)--Group 2. We compared heparin dose, sheath diameters, primary success rate, coronary care unit admissions and minor and major complications. One patient was previously anticoagulated with warfarin and all the others were on oral antiplatelet therapy before and after angioplasty. RESULTS: Primary success with the use of the Perclose system was 78%. We found no significant statistical differences between groups in respect to the presence of diabetes, sheath diameter or referral for intervention. Heparin dosage was slightly higher in group 2 (p = 0.09) and ACT was also higher in group 2 (p = 0.01). More patients in group 1 had delayed ambulation (p = 0.04) due to abciximab perfusion. In 7 patients in group 1 and 9 in group 2, additional manual/mechanical compression was needed for moderate bleeding in the first hours (p = NS). One rupture of the femoral artery with need for surgical repair (primary failure) and another delayed rupture (48 hours) occurred in group 1 (both with an associated infection), and 1 pseudoaneurysm in a patient from group 2, without abciximab but taking warfarin (p = NS). None of the variables analyzed determined the occurrence of complications. Only oral anticoagulation determined the occurrence of major complications. CONCLUSIONS: User of the Perclose system for percutaneous closure of the femoral artery in patients undergoing coronary angioplasty with simultaneous use of abciximab was not associated with greater morbidity than in patients without glycoprotein IIb/IIIa receptor antagonists.

Lymphoma with clinical presentation of a primary pericardial tumor.

Primary malignant cardiac tumors, particularly lymphoma, are rare entities. Cardiac involvement or metastization of the heart from neoplasia located elsewhere are more frequently found. We present the case of a 79-year-old patient admitted with heart failure symptoms with a 3-week evolution. Evaluation led to the identification of a cardiac tumor with unusual clinical presentation and with a rapid and fatal evolution. Pathologic analysis identified a B-cell non-Hodgkin lymphoma.

Recurrent myocardial infarction in a patient with papillary fibroelastoma.

This report describes a case of a 62 year-old man admitted for recurrent myocardial infarction and normal coronary arteries, caused by coronary embolism from aortic papillary fibroelastoma. Other conditions causing acute coronary syndrome and normal coronary arteries are discussed. A careful evaluation by transthoracic and transesophageal echocardiography is required in this clinical setting. Surgical excision of the tumor is safe and curative.

Evidence-based percutaneous closure of the left atrial appendage in patients with atrial fibrillation.

Atrial fibrillation is the most common cardiac arrhythmia, and its prevalence is increasing. Cardioembolic stroke, most of the times secondary to thrombus formation in the left atrial appendage, is its most feared and life threatening consequence. Oral anticoagulation with vitamin-K-antagonists is currently the most used prophylaxis for stroke in patients with atrial fibrillation; unfortunately, its benefits are limited by a narrow therapeutic window and an increased risk for bleeding, making it often undesired. Percutaneous occlusion of the left atrial appendage is a novel alternative strategy for cardioembolic stroke prophylaxis in patients with atrial fibrillation at a high risk of stroke but with contraindication for long-term oral anticoagulation therapy. At present, several devices have been developed specifically for percutaneous occlusion of the left atrial appendage. Current results show good feasibility and efficacy for these devices, with a high rate of successful implantation, although also associated with the inherent potential periprocedural complications. This work reviews the current state of the art of percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation.