Early ganglion stellate blockade as part of two-step treatment algorithm suppresses electrical storm and need for intubation

BACKGROUND

For the treatment of patients with electrical storm (ES), we established a two-step algorithm comprising standard anti-arrhythmic measures and early ultrasound-guided stellate ganglion blockade (SGB). In this single-center study, we evaluated the short-term efficacy of the algorithm and tested the hypothesis that early SGB might prevent the need for intubations.

METHODS

Overall, we analyzed data for 70 ES events in 59 patients requiring SGB (mean age 67.7 ± 12.4 years, 80% males, left ventricular ejection fraction 30.0% ± 9.1%), all with implantable cardioverter-defibrillators (ICDs).

RESULTS

The mean time from ES onset to SGB was 13.2 ± 12.3 hours. Percentage and mean absolute reduction in shocks at 48 hours after SGB reached 86.8% (-6.3 shocks), and anti-tachycardiac pacing (ATP) declined by 65.9% (-51.1 ATPs; all P < 0.001). Patients with the highest sustained ventricular arrhythmia (VA) burden (shocks ≥10/48 h; ATPs 10-99/48 h and ≥100/48 h) experienced the highest percentage decrease in ICD therapy (shocks -99.1%; ATPs -92.1% and -100.0%, respectively). For clinical response by defined criteria and two outcome periods (1/no sustained VA ≤48 hours post SGB, and 2/no ICD shock or <3 ATPs/day from day 3 to discharge/catheter ablation/day 8), 75.7% and 76.1% experienced complete response, respectively. Catecholamine support, no/low-dose β-blocker therapy, polymorphic/mixed-type VA, and baseline sinus rhythm versus atrial fibrillation were more frequent in patients with early arrhythmia recurrence. Temporary Horner's syndrome occurred in 67.1%, and no other adverse events were recorded. Intubation and general anesthesia during and after SGB were not needed.

CONCLUSION

The presented two-step algorithm for treating ES proved efficacious and safe. The results support implementation of early SGB in routine ES management.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Ganglion stellate blockade in the treatment algorithm of the malignant electric storm: one center, five years and 72 procedures in 59 patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant electric storm (ES) is a life-threatening condition with a high mortality rate. With years of increasing numbers of implanted ICDs, we witness increasing numbers of patients treated for ES. The role of local suppression of sympathetic nerve activity using ultrasound-guided anesthetic ganglion stellate blockade (GSB) is still under investigation with the first favorable published data from prospective cohorts.

Objective

To present data from a cohort of consecutive patients treated for ES at our cardiac center using a two-stage algorithm including GSB.

Method and Cohort

Between 2017 and 2021, 59 patients were treated using the two-stage algorithm ( when the first stage of standard procedures failed - ions, antiarrhythmic drugs, ischemia correction, heart rate modification, sedation, and GSB was performed as the second stage of the algorithm when ventricular arrhythmia recurred) in 72 GSB procedures.

57 GSB in men (79.2%)/15 GSB (20.8%) in women. Mean age 68.1 +/- 12.1 years. Mean LV EF 29.6 +/- 8.9%. 22 GSB in diabetic patients (30.6%). Ischemic etiology of ES in 41 cases (56.9%). Monomorphic ventricular tachycardia dominated among arrhythmias with 53 cases ( 73.6%). Betablocker and amiodarone were administered in 67 and 56 cases, respectively ( 93.1 and 77.8%).

A statistically significant decrease of 87.7% in ventricular arrhythmias treated with shock ICD or ATP was seen ( decrease from 57.2 to 1.43 episodes 48 hours before vs. 48 hours after GSB, p&lt;.0001) (Table 1).

Hemodynamically unstable patients on continuous catecholamines responded significantly less to the two-step algorithm, including GSB. Horner’s syndrome and other demographic and medication parameters did not appear to predict a better response to GSB (Table 2 ). No serious adverse events were observed. In one case, intermittent ( couple hours) vocal chord paresis after bilateral GSB has been observed.

Conclusion

The two-stage algorithm for the treatment of ES, including ganglion stellate blockade, has shown stable high efficacy over the years with exceptional safety. However, the actual efficacy must be proven in a double-blinded study to allow the widespread method to the clinical practice.

Structure, organization, and practical functioning of the sports cardiology center of the Nemocnice Agel Trinec Podlesi

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiological care of athletes worldwide is focused on prevention of cardiovascular disease, diagnosis, and follow-up of abnormalities in preventive screening, and subsequent therapy of detected pathologies with risk assessment for sport. The Czech Society of Sports Medicine and the Czech Cardiology Society responded to this process by establishing sports cardiology centers in the early 2020s. The centers were established in Olomouc, with two centers in Prague and Trinec.

Structure and organization

The Trinec Centre of Sports Cardiology (CSK) is organized based on tribal doctors of the Cardiocentre of the Agel Třinec-Podlesí Hospital and external cardiological collaborators from Silesia and Moravia. These doctors are trained in sports cardiology.

The practical functioning of the center is based on gradual steps: A) The patient logs in to our way through the web interface, where the essential information and previous examinations are given. B) The center's coordinator will incorporate these input data, will ensure communication with the client, other necessary information or examination, and after consultation with cardiologists, who subspecialize in the subunits, will establish a treatment plan. C) The CSK nurse ensures the organizational aspects of the established procedure. D) After the follow-up examination, the client has a final consultation with the sports cardiologist, where the suitability or limitations for sport and other recommendations for dispensation are always indicated. See Figure 1.

Cohort of athletes

Retrospective analysis of athletes from 1/2020 - 10/2021: 71 athletes, 26.0 +/- 1.5 years (15-61), 10 females (16%)/61 males: sport type: Endurance 31%, Mixed 66%. Most common indication: 46% coming in for abnormal preparticipation screening. At the conclusion of the investigation, only two were ineligible for sport, 32 eligible with condition

Conclusion

Structured, well-organized, and high-quality cardiac care for athletes is the main focus of the centers' work. In addition, the vision of our center is to provide tertiary cardiac care for athletes to reduce the risk of health complications in athletes. Therefore, our department is targeting EAPC accreditation for a sports cardiology center.

The effect of patient weight and amiodarone use on the energy of a successful shock in cardioversion of atrial arrhythmias – single-center experience study

Background

Electrical cardioversion (DCCV) is an effective method of sinus rhythm restitution. Recently published data suggest higher efficiencies of higher discharge energies. The influence of individual parameters on the success of cardioversion is still studying.

Purpose

To evaluate the influence of individual patient parameters on the energy of a successful external defibrillator shock during cardioversion of atrial arrhythmias

Methods

The retrospective analysis cohort of all patients treated by DCCV due to atrial arrhythmias between 10/2015 and 1/2020. To evaluate potential predictors for the choice of a higher initial discharge using one-dimensional logistic regression and to include parameters significant at the 10% level of significance (p&lt;0.1) in the multidimensional logistic regression model.

Results

1986 electrical cardioversions of 984 patients (382 repeated procedures of the same patients in a cohort). 1292 (65.1%) men and 694 (34.9%) women aged 67.0 (±10.2) years.

Mean energy of the first shock 118.9 (±19.2) J with a success rate of 77.8%, energy of the second shock 154.0 (±26.3) J, which increased the overall success to 80.0%, and mean high of the third shock 173.9 (±25.6) J, when the total efficacy of DCCV in sinus rhytm restitution reached 89.8%.

From the univariate binary regression, parameters significant at the 10% level of significance (p&lt;0.1) were selected and included in a multidimensional logistic regression model. Only the patient's weight and the use of amiodarone proved to be statistically significant. Weight with OR 1.21 and use of amiodarone with OR 1.43.

Conclusion

Patient weight and amiodarone use are predictors of the need to use higher energy electric cardioversion.

Discussion

Amiodarone medication does not appear to increase the defibrillation threshold, but rather is a feature that represents the group of patients treated with more aggressive antiarrhythmic therapy for advanced atrial arrhythmias with more significant structural impairment, but this attitude requires further study.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): VAVIA: IGS202009 - Racionální algoritmus při elektivní elektrické kardioverzi fibrilace síní.

Chronic refractory angina pectoris treated by bilateral stereotactic radiosurgical stellate ganglion ablation: first-in-man case report

Background

Refractory angina pectoris (AP) significantly impairs quality of life in patients with chronic coronary syndrome. Several minimally invasive methods (coronary sinus reducer, cell therapy, laser or shockwave revascularization, and spinal cord stimulation) or non-invasive methods (external counterpulzation) have been studied. However, their routine clinical use has not been widely implemented. Surgical or endoscopic sympathectomy is feasible for permanently relieving angina, but is often contraindicated due to the extent of complications associated with it. Neuromodulation by anaesthetic blockade of the left-sided stellate ganglion (SG) has been shown to relieve angina for days or weeks. To provide a long-term anti-anginal effect, novel pharmacological (phenol-based) or radiofrequency ablation techniques have been individually used to permanently destroy sympathetic pathways.

Case summary

We describe a first-in-man use of stereotactic radiosurgical SG ablation using a linear accelerator (CyberKnife) in a heart failure patient after myocardial infarction with chronic refractory AP. Repeated anaesthetic SG blockade in this patient resulted in a significant, but only short-term, clinical improvement. The left, and subsequently the right, SG was ablated by targeted irradiation. During the 1-year follow-up, the patient remained without angina. We did not observe any clinically relevant early or late complications. Atrial fibrillation that developed 2 months after the second procedure was deemed to be associated with a natural progression of co-existing heart failure.

Discussion

We conclude that stereotactic radiosurgical SG ablation has the potential to become a minimally invasive and low-risk procedure to treat refractory angina patients. However, this procedure needs to be evaluated in larger patient populations.

Malignant arrythmic storm, stellate ganglion and diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant arrhythmic storm (MAS) increases mortality more than three-fold according to current data. In the acute setting, besides resolving reversible causes, antiarrhythmics are the mainstay of treatment. The role of suppressing the local sympathetic nervous system activity, using stellate ganglion block (SGB) for example, is still being investigated. 

Purpose

To show short-term efficacy of SGB in suppressing the ventricular arrhythmia recurrence in MAS. To identify subgroups of patients with better clinical response after SGB.

Methods

All consecutive patients with MAS, with standard treatment failure and ventricular arrhythmia recurrence, treated with ultrasound guided SGB, instilating 7ml of 0,5% Bupivacain.

58 MAS treated with SGB durin 2017 – 2020. There were 49 men (84,5%), average age 68,7 +/- 11,4, with average left ventricular EF 28,9 +/- 8,43%. There were 17 diabetics (29,3%). 

Results

When we compare the numbers of defibrillations for sustained ventricular tachycardia 48 hours before and 48 hours after SGB, being the primary therapeutic endpoint in MAS, we see a 96,7% reduction (p &lt; 0,001). When we evaluate ventricular arrhythmias treated with both antitachycardia pacing and shocks, then we see 90% reduction (p &lt; 0,001). The effect of SGB in ventricular arrhythmia suppression was statistically significant during the entire follow-up of 8 days.

When we analyzed the cohort, looking for groups showing better response after SGB in terms of ventricular arrhythmia reduction, the only group showing statistical significance in this regard are patients with diabetes mellitus. 

Conclusions

In our cohort, stellate ganglion block is exceptionally effective in the treatment algorithm of malignant arrhythmic storm. SGB shows significantly higher efficacy in the subgroup of patients with diabetes mellitus. Abstract Figure. VA before and after BSG

P5698What predicts the inefficiency of stellate ganglion block in the treatment of electrical storm?

Introduction

Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective.

Purpose

To identify predictors of SGB failure in patients with ES.

Methods

We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018.

Results

Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy.

Conclusions

According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.

P4609The use of stellate ganglion block in the management of electrical storm reduces VA burden by 92% and completely excludes the need for general anesthesia

Background

The electrical ventricular storm (ES) is a life-threatening condition. The treatment is based on addressing the triggering cause, influencing reversible factors, patient sedation, and antiarrhythmics. Suppressing the massive sympathetic surge is a keystone in the emergent management. Stellate ganglion block (SGB) might serve this purpose.

Purpose

To show the efficacy of ultrasound-guided SGB in the management of ES.

Methods

Retrospective analysis of case series. All ES patients in whom SGB was used. SGB was performed after the initial failure of reversible factors modification + sedation + antiarrhythmics. We compared the mean VA burden 2 days before vs. 7 days after SGB (to show the long effect of SGB).

31 patients (5 females). Procedure date between 01.03.2017 and 21.11.2018. Mean LVEF 27±9%. Etiology: 74% ischemic vs. 26% non-ischemic cardiomyopathy. Antiarrhythmic treatment: amiodarone 27 pt. (87%), trimecaine 3pt (10%), digoxin 2 pt. (6%), beta-blocker 28 pt. (90%).

Results

The ES management including SGB resulted in a significant decrease (92%) in VA burden (mean 26,0 episodes/day vs. 0,6 episodes/day; p<0.001). Separately, ATP episodes were reduced by 99%, external or ICD shocks by 76%. There was no need for general anesthesia as a last resort in refractory ES. 30-days mortality 12,9%. No significant adverse events have been noticed, 10 pt. (32,3%) have developed Horner syndrome, which always disappeared in 24 hours.

Conclusion

Ultrasound-guided SGB in the management of ES is safe and very effective. Randomized prospective studies are required to precisely determine the effect of SGB.

OCT guidance during stent implantation in primary PCI: A randomized multicenter study with nine months of optical coherence tomography follow-up

AIMS

To assess the possible merits of optical coherence tomography (OCT) guidance in primary percutaneous coronary intervention (pPCI).

METHODS AND RESULTS

201 patients with ST-elevation myocardial infarction (STEMI) were enrolled in this study. Patients were randomized either to pPCI alone (angio-guided group, n=96) or to pPCI with OCT guidance (OCT-guided group, n=105) and also either to biolimus A9 or to everolimus-eluting stent implantation. All patients were scheduled for nine months of follow-up angiography and OCT study. OCT guidance led to post-pPCI optimization in 29% of cases (59% malapposition and 41% dissections). No complications were found related to the OCT study. OCT analysis at nine months showed significantly less in-segment area of stenosis (6% [-11, 19] versus 18% [3, 33]; p=0.0002) in favor of the OCT-guided group. The rate major adverse cardiovascular events were comparable at nine months in both groups (3% in the OCT group versus 2% in the angio-guided group; p=0.87).

CONCLUSIONS

This study demonstrates the safety of OCT guidance during pPCI. The use of OCT optimized stent deployment in 1/3 of patients in this clinical scenario and significantly reduced in-segment area of stenosis at nine months of follow-up. Whether such improvements in OCT endpoints will have a positive impact on late clinical outcomes, they demand both a larger and longer-term follow-up study.

Correlation of geomagnetic activity with implantable cardioverter defibrillator shocks and antitachycardia pacing

OBJECTIVE

To investigate a potential relationship between implantable cardioverter defibrillator (ICD) therapies and daily geomagnetic activity (GMA) recorded in a large database.

PATIENTS AND METHODS

The ALTITUDE database, derived from the Boston Scientific LATITUDE remote monitoring system, was retrospectively analyzed for the frequency of ICD therapies. Daily GMA was expressed as the planetary K-index and the integrated A-index and was graded as levels I (quiet), II (unsettled), III (active), and IV (storm).

RESULTS

A daily mean ± SD of 59,468±11,397 patients were monitored between January 1, 2009, and May 15, 2012. The distribution of days according to GMA was as follows: level I, 924/1231 (75%); level II, 226/1231 (18%); level III, 60/1231 (5%); and level IV, 21/1231 (2%). The daily mean ± SD numbers of ICD shocks received per 1000 active patients in the database were 1.29±0.47, 1.17±0.46, 1.03±0.37, and 0.94±0.29 on level I, II, III, and IV days, respectively; the daily mean ± SD sums of shocks and antitachycardia pacing therapies were 9.29±2.86, 8.46±2.45, 7.92±1.80, and 7.83±2.28 on quiet, unsettled, active, and storm days, respectively. A significant inverse relationship between GMA and frequency of ICD therapies was identified, with the most pronounced difference between level I and level IV days (P<.001 for shocks; P=.008 for shocks + antitachycardia pacing).

CONCLUSION

In a large-scale cohort analysis, ICD therapies were delivered less frequently on days of higher GMA, confirming the previous pilot data and suggesting that higher GMA does not pose an increased risk of arrhythmias using ICD therapies as a surrogate marker. Further studies are needed to gain an in-depth understanding of the underlying mechanisms.

[Compare of misoprostol and dinoprost effectivity by induced second-trimester abortion]

OBJECTIVES

To compare the effectivity and safety of second-trimester abortion induced by two different types of prostaglandins.

TYPE OF STUDY

Retrospective study.

SETTING

Department of Obstetrics and Gynecology, University Hospital Ostrava and Department of Obstetrics and Gynecology, University Hospital Olomouc.

METHODS

Retrospective analysis of 128 second trimester abortions induced by misoprostol and 82 second trimester abortions induced by dinoprost. Total length of abortion, failure of the method, need for instrumental revision of the uterine cavity, request for epidural analgesia and length of hospital stay were compared.

RESULTS

In total 210 women were included. Misoprostol was used in 128 cases and dinoprost in 82 cases. The average gestational age was 18+1 in misoprostol group and 20+2 in dinoprost group. Ninety two percent of women with misoprostol aborted within 24 hours while in the dinoprost group it was 68%, withing 16 hours the number of completed abortions was 62% (misoprostol) versus 48% (dinoprost). The method failed in 2% of cases with misoprostol and 7% of cases with dinoprost.

CONCLUSION

We conclude that induction of second-trimester abortion with the use of misoprostol is safe, quick, non-invasive and comfortable method with low frequency of complications and side effects.

Treatment of bifurcation lesions using dedicated bifurcation stents versus classic bare-metal stents. Randomized, controlled trial with 12-month angiographic follow up

BACKGROUND

The aim of this study was to compare the use of classic bare- metal stents with dedicated bifurcation bare-metal stents in patients who were not eligible for drug-eluting stents (DES) implantation.

METHODS

Sixty patients with bifurcation stenosis were randomly assigned to received either a dedicated bifurcation or a bare-metal stent (n = 30) or classic bare-metal stent (n = 30) with stenting of the parent vessel and angioplasty/or provisional stenting of the side branch. Fifty-nine patients underwent 12-month clinical and angiographic follow up unless this was performed earlier due to symptoms. Dual antiplatelet treatment was administered for 1 month. Acute success as well as the long-term clinical and angiographic outcome have been assessed in both groups.

RESULTS

Baseline demographic, angiographic and procedure-related characteristics were well balanced in both groups. The use of dedicated stents was associated either with reduced procedure or fluoroscopy time (34 +/- 9 minutes vs. 46 +/- 20 minutes; p = 0.004 and 9 +/- 6 minutes vs. 15 +/- 9 minutes; p = 0.003, respectively) and lesser contrast volume (168 +/- 86 milliliters vs. 199 +/- 103 ml; p = 0.02). At the 12-month follow up, no statistically significant difference was found between both groups regarding major adverse cardiovascular events (MACE) (13.7 vs. 13.3%; p = 0.9).

CONCLUSIONS

In our study we failed to demonstrate the superiority of a dedicated stent versus classic a bare-metal stent for the treatment of bifurcation lesions regarding MACE in patients who were not eligible for DES implantation. However, the use of dedicated stents may be preferable due to reduced procedure and fluoroscopy time and lesser contrast volume.

The lack of endothelization after drug-eluting stent implantation as a cause of fatal late stent thrombosis

The authors present a fatal case of late thrombosis of paclitaxel-eluting stent implanted in the left main stem occurring 6 months after the procedure and 3 weeks after the cessation of clopidogrel. An autopsy has shown the lack of endothelization of deployed stent.

Serum copper as a marker of inflammation in prediction of short term outcome in high risk patients with chronic heart failure

BACKGROUND

Oxidative process and inflammation are regarded as important factors in the pathogenesis of chronic heart failure. Our study was aimed at investigating the prognostic value of serum copper levels in high risk subjects with chronic heart failure.

METHODS

Serum copper levels and other prognostic indicators were determined in the group of 60 patients with chronic heart failure due to ischemic heart disease: 30 consecutive subjects with acute decompensation of chronic heart failure (acute group A) and 30 patients with chronic stable heart failure (group B). Patients were followed prospectively 12 months. Primary end-point was the mean time to death and/or heart failure hospital admission.

RESULTS

The mean time to death was in the group A 279.4+/-18.9 days and 351.7+/-13.6 days in the group B (p<0.0001). Cox proportional hazard model revealed that the time to death for all subjects (n=60) was affected by cardiothoracic ratio (p<0.001). The time to combined end-point death or hospital admission was affected by serum copper concentration (p<0.0001).

CONCLUSION

Serum copper levels predicted short term outcome in high risk patients with chronic heart failure.

“Head-to-head comparison between sirolimus-eluting and paclitaxel-eluting stents in patients with complex coronary artery disease: An intravascular ultrasound study”

BACKGROUND

The aim of this study was to assess neointimal hyperplasia following sirolimus-eluting (SES) and paclitaxel-eluting stents (PES) implantation in a patients with complex coronary disease.

METHOD

Between January to December 2004, 70 patients were enrolled in this study (SES = 37; PES = 33. The primary objective was to assess the efficacy of SES and PES on neointimal proliferation inhibition in patients with complex coronary lesions by volumetric 3D intravascular ultrasound (IVUS) assessment at six-month follow-up.

RESULTS

Baseline clinical, demographic or angiographic characteristics were well balanced in both groups. All procedures as well as hospitalisation were uneventful. The percentage of B2/C lesions in our study was > 90% in both groups. The IVUS-assessed in-stent mean neointimal hyperplasia volume was significantly lower in lesions treated with SES compared to PES (4.1 +/- 11 mm3 vs. 17.4 +/- 23 mm3, p < 0.002) at 6 month follow-up. No difference in both MACE (3.0 versus 6.0%, p = NS) and restenosis (5.4 versus 9.1%, p = NS) were found. The in-segment late loss at six month was 0.26 mm in the SES and 0.48 mm in the PES group (p = NS).

CONCLUSIONS

The present study showed reduced neointimal proliferation after sirolimuseluting as compared to paclitaxel-eluting stents in patients with complex coronary artery disease. Both SES and PES were associated with low rate of angiographic restenosis or major adverse cardiovascular events.

[Distal protection during primary coronary angioplasty in patients with acute myocardial infarction]

BACKGROUND

The aim of the study was to assess the safety, feasibility and efficacy of mechanical distal protection during primary angioplasty using FilterWire EZ (FW).

METHOD AND RESULTS

Thirty-one patients with acute myocardial infarction (AMI) were treated by primary angioplasty with distal protection using FW. The results were compared with a matched control group consisting of 33 patients with AMI treated by primary angioplasty alone. Successful FW positioning was obtained in 30 patients (97%). In these patients a lower rate of distal embolisation (3 vs. 18%, p=0.04) was found and a more effective reperfusion was assessed by ST elevation's resolution >50% immediately after the procedure (83 vs. 61%, p=0.05). A higher number of patients with corrected TIMI frame count <27 in FW group supported more effective reperfusion to but this difference did not reached statistical significance (87 vs. 73%, p=0.09). There were no differences between groups regarding average peak CK and CK-MB. However, there is a trend to lower release in FW group (32.1+/-24.5 vs. 35.3+/-31.0, p=0.33; 4.2+/-3 vs. 4.4+3.7, p=0.44).

CONCLUSIONS

The presented study confirmed that distal embolisation during primary angioplasty is a frequent phenomenon. In this setting, adjunctive use of the FW is feasible and save, and it may improve myocardial reperfusion by reducing the embolic events.

Difference of baseline serum copper levels between groups of patients with different one year mortality and morbidity and chronic heart failure

BACKGROUND

Serum copper concentrations as indicators of non-specific inflammatory response are higher in patients with severe heart failure than in patients with mild to moderate cardiac insufficiency and correlate with acute phase protein concentrations. The aim of this study was to find out if baseline serum copper concentrations are higher in patients with chronic heart failure and higher one year mortality and morbidity and whether serum copper concentrations correlate with prognostic indicators.

METHODS AND RESULTS

Baseline serum copper concentrations were determined in 64 patients with chronic heart failure, functional classification NYHA II-IV (NYHA - New York Heart Association), caused by ischemic heart disease, with severe left ventricular dysfunction (ejection fraction < or = 35%). 30 patients died or were admitted to the hospital because of worsening heart failure (group A) within 12 months since their examination. 34 patients did not die and hospitalisation was not necessary within 12 months (group B). Retrospectively the presence of differences in serum copper concentrations and in prognostic indicators was assessed between both groups. Statistically significant differences between both groups were found in these parameters: baseline serum copper concentrations (p < 0.001), ejection fraction of left ventricle (p < 0.05), baseline heart rate (p < 0.01) and cardiothoracic ratio (p < 0.01). Serum copper concentrations significantly correlate with heart rate (p < 0.01), inverse correlation with left ventricular ejection fraction and positive correlation with cardiothoracic ratio are not statistically significant.

CONCLUSIONS

Baseline serum copper concentrations are significantly higher in patients with chronic heart failure, also correlating with higher one-year mortality and morbidity. Serum copper levels significantly correlate with baseline heart rate. Relation of serum copper concentrations with left ventricular ejection fraction and cardiothoracic ratio is not statistically significant.

[In Time? Time interval between first symptoms to hospital admission of patients with acute coronary syndromes]

OBJECTIVE

To assess the pre-hospital delay, i.e. the period which elapses between the onset of pain on the chest and admission to hospital in patients hospitalized on account of acute coronary syndrome. To analyze factors which influence this time interval and obtain thus data for a strategy leading to reduction of the pre-hospital delay.

METHOD

Collection of data by means of a questionnaire focused on the time of onset of pain on the chest, time of contact with the health service, time of admission to hospital, type of transport of the patient to hospital, socioeconomic data, manifestations of ischaemic heart disease during the premorbid period and health care provided. Statistical evaluation by the non-paired Mann-Whitney test.

RESULTS

Data were assembled from 126 patients admitted to hospital on account of acute coronary syndrome. The median of pre-hospital delay was 5 hours 40 mins., the median of the patient's hesitation 3 hours 44 mins., the median of the transport period was 59 mins. The pre-hospital delay is significantly reduced by transport by the rapid emergency service (p < 0.0001), dispensary care of a cardiologist (p < 0.02) and a previous hospitalization on account of acute myocardial infarction or unstable angina pectoris (p < 0.04). Pre-hospital delay is significantly prolonged in old age pensioners (p < 0.05). On the borderline of signficance is the reduction of pre-hospital delay in patients younger than 80 years (p < 0.06) and patients with higher than elementary education (p = 0.102).

CONCLUSION

Prehospital delay in the investigated group is almost three times longer as compared with data from abroad. A most significant part in this delay is played by the long hesitation of patients and transport of the patient to the health institution by other means than the rapid emergency service. In order to provide effective treatment to a larger number of patients with acute coronary syndrome within the shortest time interval it is necessary to inform the population at large on the importance of sudden pain on the chest and the necessity of the quickest possible contact with the rapid emergency service on phone 155. Only then can we expect further improvements of the prognosis of these patients.

[Relation between levels of acute phase proteins and copper and the parameters of systolic and diastolic left ventricular function in patients with chronic heart failure]

BACKGROUND

Acute phase protein concentrations and serum copper levels in patients in acute phase of myocardial infarction were significantly higher in subjects with heart failure compared to patients with non-complicated course of myocardial infarction. Acute phase protein concentrations correlated with the parameters of the left ventricular systolic function in patients in acute phase of myocardial infarction. The aim of the study was to evaluate the relation of acute phase protein concentrations and serum copper levels with the parameters of left ventricular systolic and diastolic function in patients with chronic heart failure out of the acute phase post myocardial infarction.

METHODS AND RESULTS

Authors analysed relation between the acute phase proteins, C-reactive protein, fibrinogen, and copper concentrations and the left ventricular systolic and diastolic function assessed by echocardiography in 38 patients (26 men and 12 women, average age 68 years) with chronic heart failure and advanced left ventricular systolic dysfunction post myocardial infarction with ejection fraction lower or equal to 35%. Serum C-reactive protein concentrations correlated significantly with the left ventricular ejection fraction (r = -0.38, p < 0.05) and with isovolumic relaxation time IRVT (r = -0.51, p < 0.001)--inverse correlation. C-reactive protein concentration correlated with the ratio of the maximal flow velocity of the early transmitral diastolic filling (E vave) and with the maximal transmitral flow velocity during atrial contraction (A wave)--E/A ration (r = 0.43, p < 0.01). C-reactive protein concentration also correlated with the ration of the time velocity integrals of the E wave and the A wave--TVIE/TVIA (r = 0.45, p < 0.01)--positive correlation. Correlation between the fibrinogen and copper concentrations and the left ventricular ejection, or that with parameters of the diastolic left ventricular function were not statistically significant.

CONCLUSIONS

Study revealed significant correlation between C-reactive protein concentration and parameters of the left ventricular systolic and diastolic function in patients with chronic heart failure post myocardial infarction. Correlation between copper and fibrinogen levels and parameters of the left ventricular function was not significant.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study

AIMS

Direct angioplasty is an effective treatment for ST-elevation myocardial infarction. The role of very early angioplasty in non-ST-elevation infarction is not known. Thus, a randomized study of first day angiography/angioplasty vs early conservative therapy of evolving myocardial infarction without persistent ST-elevation was conducted.

METHODS

One hundred and thirty-one patients with confirmed acute myocardial infarction without ST-segment elevations were randomized within 24 h of last rest chest pain: 64 in the first day angiography/angioplasty group and 67 in the early conservative group (coronary angiography only after recurrent or stress induced myocardial ischaemia).

RESULTS

All patients in the invasive group underwent coronary angiography on the day of admission (mean randomization-angiography time 6.2 h). First day angioplasty of the infarct related artery was performed in 47% of the patients and bypass surgery in 35%. In the conservative group, 55% underwent coronary angiography, 10% angioplasty and 30% bypass surgery within 6 months. The primary end-point (death/reinfarction) at 6 months occurred in 6.2% vs 22.3% (P<0.001). Six month mortality in the first day angiography/angioplasty group was 3.1% vs 13.4% in the conservative group (P<0.03). Non-fatal reinfarction occurred in 3.1% vs. 14.9% (P<0.02).

CONCLUSIONS

First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.

[Serum copper levels in patients with chronic heart failure associated with systolic left ventricular dysfunction and its relation to the severity of cardiac failure]

The authors examined the serum copper concentrations in a group of 40 patients with chronic heart failure and significant systolic left ventricular dysfunction with an ejection fraction of less than 35%. In 21 patients the examination was made on admission to hospital on account of deterioration of cardiac insufficiency (group A), in 19 patients with stable chronic cardiac failure the examination was made at the out-patient department (group B). Assessment of serum copper concentrations was made by the method of absorption spectrophotometry under standard conditions. Assessment of the ejection fraction of the left ventricle and dimensions of the cardiac compartments was made by two-dimensional echocardiography. The heart rate was assessed from the electrocardiogram at rest.

RESULTS

The authors found statistically significantly higher copper concentrations in patients of group A (19.78 +/- 1.67 mumol/l) as compared with group B (14.80 +/- 1.54 mumol/l, p < 0.001). The correlation between copper concentrations, the left ventricular ejection fraction, dimensions of the cardiac compartments and heart rate are not significant.

CONCLUSION

Serum copper concentrations in patients with chronic heart failure and significant systolic left ventricular dysfunction are related to the severity of the disease and are higher in patients admitted on account of cardiac insufficiency than in patients with stable cardiac failure.

[Serum copper levels in patients with acute and chronic types of ischemic heart disease and its relation to lipoprotein levels and extent of coronary atherosclerosis]

The authors assessed serum copper and lipoprotein concentrations in a group of 67 patients hospitalized successively at the cardiological department. During hospitalization they were subjected to selective coronarography with assessment of the angiographic score. In 35 patients the angiographic examination was made during the chronic stage of IHD (group A), in 32 patients it was indicated on account of acute coronary syndrome (group B). The authors found that serum copper concentrations are significantly higher in patients with acute forms of IHD (group B, p < 0.001). Serum copper concentrations do not correlate significantly with lipoprotein concentrations nor with the extent of coronary atheroclerosis (angiographic score).

Improvement in exercise tolerance and symptoms of congestive heart failure during treatment with candesartan cilexetil. Symptom, Tolerability, Response to Exercise Trial of Candesartan Cilexetil in Heart Failure (STRETCH) Investigators

BACKGROUND

The renin-angiotensin system plays an important part in the pathogenesis of congestive heart failure (CHF). This study evaluated the effect of an angiotensin II type 1 receptor antagonist on exercise tolerance and symptoms of CHF.

METHODS AND RESULTS

In this multicenter, double-blind, parallel-group study, 844 patients with CHF were randomized to 12 weeks' treatment with placebo (n=211) or candesartan cilexetil 4 mg (n=208), 8 mg (n=212), or 16 mg (n=213) after a 4-week placebo run-in period. Changes in exercise time, Dyspnea Fatigue Index score, NYHA functional class, and cardiothoracic ratio were determined. Candesartan cilexetil produced a dose-related improvement in exercise time. For the intention-to-treat population, the increase produced by candesartan cilexetil 16 mg was significantly greater than that produced by placebo (47.2 versus 30.8 seconds, P=0.0463). All doses of candesartan cilexetil significantly improved the Dyspnea Fatigue Index score relative to placebo. NYHA class improved more frequently in the candesartan cilexetil groups; the differences relative to placebo were not significant. The decrease in cardiothoracic ratio with candesartan 4 to 16 mg was small but statistically significant compared with placebo (all P<0.05). In all candesartan cilexetil groups, plasma renin activity and angiotensin II levels increased from baseline and aldosterone levels decreased in the 8- and 16-mg treatment groups. Candesartan cilexetil was well tolerated at all doses.

CONCLUSIONS

In summary, treatment with candesartan cilexetil demonstrated significant improvements in exercise tolerance, cardiothoracic ratio, and symptoms and signs of CHF and was well tolerated.

Ventricular arrhythmias in myocardial hypertrophy of various origins

It has not been explained whether the etiological substrate of left ventricular hypertrophy has any influence on prevalence and severity of ventricular arrhythmias. Therefore, 48 h ambulatory electrocardiographic monitoring findings were compared in two groups of untreated patients without coronary artery disease and with no significant differences in age, sex, maximal and average myocardial thickness and left ventricular systolic function. Group A comprised 42 patients with pressure overload hypertrophy due to essential hypertension, and group B comprised 42 patients with hypertrophic cardiomyopathy. The prevalence of complex ventricular arrhythmias (Lown 3a-4b) was high in both groups (65% versus 60%, respectively, not significant). No significant difference was found in total frequency of most serious arrhythmias: Lown 4a, 26 versus 21 events (not significant), and Lown 4b, 20 versus 28 events (not significant). There was a correlation between prevalence of complex ventricular arrhythmias and maximal myocardial thickness in both groups of patients (P < 0.05), and, in group A only, between prevalence of complex ventricular arrhythmias and age (P < 0.01). It was concluded that, although the etiology of pressure overload hypertrophy of the left ventricle and that of hypertrophic cardiomyopathy are completely different, the overall prevalence and spectrum of ventricular arrhythmias in both types of hypertrophy are identical.

[The effect of isometric loading on diastolic left ventricular filling in healthy individuals studied by the Doppler technic]

The authors examined by Doppler echocardiography 30 subjects aged 21-30 years, exposed during examination to an isometric load by using a manual balloon dynamometer. The authors investigated different indicators of left ventricular filling during diastole and their indexes which evaluate indirectly the left ventricular diastolic function. The assessed correlations of some indicators with the quantitative expression of the isometric load (double product) were as follows: peak speed E - r = 0.3671 (p < 0.05), peak speed A - r = 0.6098 (p < 0.001), index of rations of peak speeds E/A - r = 0.6098 (p < 0.0001, sum of speed--time integrals TVIE + TVIA - r = 0.6469 (p < 0.001) and the time of retardation of the early filling phase of the left ventricle related to the heart rate DCT/TF - r = 0.7249 (p < 0.001). A statistically significant increase during the load was recorded in the peak speed A and a reduction of the E/A ratio (p < 0.01). The time speed integral TVIE increased (p < 0.01), both indexes TVI E + A and TVI E/A declined (p < 0.05). The time of retardation of the early filling stage to the early filling time DCT/DFT increased (p < 0.05) and DCT in relation to the heart rate DCT/TF declined significantly (p < 0.01). There was an insignificant decline of the peak speed of early filling E and its time-speed integral, TVI E. The sum of time-speed integrals TVIE + A did not change significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

[The character of left ventricular filling measured by pulsed Doppler echocardiography in patients with various degrees of arterial hypertension]

The authors assessed, using Doppler echocardiography under standard conditions, indicators of left ventricular filling in 95 patients, mean age 52 years, with arterial hypertension of varying severity. The patients were divided into four groups: Group I--Patients with severe hypertension and concentric hypertrophy of the left ventricle (LV). Group II--Patients with severe hypertension without organ changes. Group III--Patients with mild hypertension without organ changes. Group IV--Patients with severe hypertension, hypertrophy of the LV and signs of its failure grade II according to Killip's classification. The results were compared with findings in a group of 30 normal subjects of similar age. In all groups of patients statistically significant differences were found in the type of left ventricular filling, as compared with normal subjects. In less severe affection of left ventricular function, where impaired active relaxation of musculature predominates (groups I, II and III), the left ventricular filling during early diastole was reduced, slower and its main part was shifted to the late stage of diastole. The ratio of the late and early flow rate through the mitral orifice Av/Ev and the ration of time/rate integrals of these rates, TVIA/TVIE, were elevated, as compared with normal subjects, similarly as the time value of retardation of early diastolic flow through the mitral orifice corrected with regard to the heart rate, DT/TF. The value of maximal flow through the mitral orifice during early diastole, PFRB was reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical interpretation of the character of mitral valve flow in relation to diastolic properties of the left ventricle]

Based on their own experience and data in the literature the authors describe the Doppler method of evaluation of properties of the left ventricle. In patients with early disorders of the diastolic function, when above all relaxation of the left ventricle is affected, a reduced rate of early diastolic filling (E) is a typical finding. There is also compensatory increase in the rate of filling during auricular contraction (A) with the appropriate increase of the A/E ratio and the ratio of rate velocity integrals (TVIA/TVIE). At the same time the maximal flow through the mitral orifice is reduced during early diastole (PFR), the deceleration time is protracted and so is the time of isovolumic relaxation. For more advanced stages of cardiac damage when impaired compliance of the left ventricle predominates, typical features are the so-called restrictive type of filling with a high rate of E, short DT and a relatively low velocity A. There exists a number of intermediary types between these extreme types of flow. The final shape of the flow curve is influenced also by the actual haemodynamic condition of the subject (heart rate, pre-load, after-load, pressure in left, ventricle, left ventricular systolic function etc.). The authors draw therefore attention to possible errors during interpretation of assessed indicators. In the conclusion they recommend methodical principles for examination of left ventricular diastolic function by Doppler echocardiography. Above all it is necessary to respect restrictions due to valvular defects, arrhythmias, the action of drugs with haemodynamic action, the presence of signs of left ventricular failure, the influence of respiration on the flow rate, etc.

[The effect of stimulated tachycardia on diastolic left ventricular filling in patients with ischemic heart disease]

The authors examined 20 patients with ischaemic heart disease (IHD) by pulsed Doppler echocardiography before and after a load of stimulated tachycardia. The character of left ventricular filling depended on the blood pressure reading in a wedged position only in patients who had an elevated pressure (r = -0.65 and r = -0.81 resp. after a load for A/E, r = -0.62 and r = -0.79 after a load for DT). When the pressure is normal, it declines in a wedged position and the left ventricular filling in early diastole becomes protracted and the ratio of the atrial filling rises (A/E increased after the load p greater than 0.001, DT was protracted after the load p greater than 0.01). This change is due in particular to the protracted relaxation of the heart muscle. When the pressure is elevated in a wedged position, i.e. when the elasticity of the left ventricle declines, the rate of early filling rises and its duration is reduced. This relationship was more marked after the load (A/E after the load declined p greater than 0.01, DT after the load was shorter p greater than 0.001). Examination of the flow through the mitral orifice after a load by stimulated tachycardia makes it possible to differentiate patients with a mild and more severe affection of the left ventricle associated with IHD. It permits also prediction of an increased intraventricular pressure and this to monitor the course of the disease or to evaluate the success of treatment.

[Diastolic function of the hypertrophic left cardiac ventricle in hypertensive patients evaluated with Doppler echocardiography]

The authors examined by Doppler and one-dimensional echocardiography 20 patients with concentric hypertrophy of the musculature of the left ventricle and hypertension and 20 healthy subjects of similar age. As compared with the control group, they found in all patients deterioration of indicators of left ventricular diastolic function. The rate of blood flow in the early diastolic phase (Ev) was reduced and the ratio of the atrial contraction (Av) in the filling of the left ventricle increased (p less than 0.001). The maximal blood flow across the mitral orifice in early diastole (PFR) was lower (p less than 0.05) and the slowing down of the early diastolic flow (E-F) was more marked (p less than 0.001). The peak rate of relaxation (Vr) was also lower in the group of hypertonics (p less than 0.01). These disorders are an early sign of cardiac affection in hypertension and precede changes of systolic function. The impaired diastolic function is directly proportional to the weight of the left ventricle (for Av/Ev r = 0.76, PFR r = 0.68, E-F r = -0.82). The results of examinations obtained by Doppler echocardiography correlate with relaxation of the myocardium of the left ventricle assessed by computer processing of the TM echocardiogram (for Av/Ev r = 0.72, DHT r = 0.66, E-F r = 0.76).

[Diastolic function of the left heart ventricle and new possibilities for its evaluation]

The authors present a brief account of contemporary findings pertaining to the physiology and pathophysiology of the diastolic phase of the cardiac cycle. The abnormal diastolic function of the left ventricle is documented best in ischaemic heart disease and hypertension with left ventricular hypertrophy. In these conditions the mechanisms of the development of impaired left ventricular diastolic function are described in more detail. These disorders are the early stage of affection of the heart muscle and do not depend on the quality of systolic function of the left ventricle. Isolated disorders of left ventricular diastolic function may be the cause of left-sided cardiac failure. The authors deal also with invasive and non-invasive methods which make examination of diastolic function possible and discuss in more detail Doppler visualization of the blood flow across the mitral valve.

[The effect isometric exertion on left ventricular function in patients after myocardial infarct]

24 patients, after transmural cardiac infarction, were exposed to isometric exercise ("handgrip"). The haemodynamic response was checked by means of impedance plethysmography. The stroke volume decreased on average from 64 +/- 14 to 60 +/- 15 ml (p less than 0.05), cardiac output increased from 4.8 +/- 1.0 to 5.4 +/- 1.2 l/min. (p less than 0.01). Peripheral resistance significantly increased and left ventricular performance was non-significantly reduced. Compared with a group of healthy control, their stroke and cardiac output and cardiac work kept increasing during isometric exercise. Isometric exercise is an adequate means of checking left ventricular performance.

[Reliability of electrocardiographic signs in left atrial enlargement. Electrocardiographic and echocardiographic study]

In 85 patients with left atrial enlargement proved by echocardiography the authors tested the information capacity of electrocardiography for the diagnosis of this disorder. Only in half the patients enlargement of this cardiac cavity could be assumed from the electrocardiogram. From the results ensues the small sensitivity of ECG signs of enlargement of the left atrium.