Articles

Fibrinolytic therapy has become synonymous with tissue plasminogen activator (tPA) based on the belief that tPA alone was responsible for natural fibrinolysis. Although this assumption was belied from the outset by disappointing clinical results, it persisted, eventually causing fibrinolysis to be discredited and replaced by an endovascular procedure. Since time to reperfusion is the critical determinant of outcome, which in acute myocardial infarction (AMI) means within two hours, a time-consuming hospital procedure is ill-suited as first line treatment. For this purpose, fibrinolysis is more fitting. The assumption that tPA is responsible for fibrinolysis is contradicted by published findings. Instead, tPA ‘s function is limited to the initiation of fibrinolysis, which is continued by urokinase plasminogen activator (uPA) and that has the dominant effect. tPA and uPA gene deletion and clot lysis studies showed the activators have complementary functions, requiring both for a full effect at fibrin-specific doses. They are also synergistic in combination thereby requiring lower doses for efficacy. A clinical proof of concept study in 101 AMI patients who were treated with a 5 mg bolus of tPA followed by a 90 minute infusion of prouPA, the native form of uPA. A near doubling of the 24 h TIMI-3 infarct artery patency rate was obtained compared to that in the best of the tPA trials (GUSTO). In further contrast to tPA, there were no reocclusions and the mortality was only 1% [1]. A sequential combination of both activators, mimicking natural fibrinolysis, holds promise to significantly improve the efficacy and safety of therapeutic fibrinolysis.

Objective: The long-term outcome of percutaneous transluminal angioplasties is mainly determined by restenoses, either by progression of the underlying disease or by intimal hyperplasia. Pharmacological substances on the one hand and the implantation of stents on the other have been developed with the intention of preventing precisely this complication. While patients are treated after PTA of peripheral vessels with different low-molecular-weight heparins, the indication for stent implantation is determined individually rather by experience. The aim of this study was to determine gender-specific risk factors of long-term outcome after percutaneous transluminal angioplasty (PTA) of peripheral vessels with or without stentimplantation. Methods: In the present study, we examined the long-term results of percutaneous transluminal angioplasty (PTA) of peripheral vessels. Between 2007 and 2017, in total, 3,276 patients underwent PTA with or without stent implantation in our clinic. All patients were treated postinterventionally for 48 hours with 25,000 IU heparin (Unfractionated Heparin (UFH), heparinsodium-Braun, 25,000 I.E./5 ml, 2 ml/h) monitored by the partial thromboplastin time and subsequently underwent a control investigation every 6 months. The endpoint of the study was determination of symptomatic stenosis larger than 50% that required reintervention. Results: 239 (68.2% with mean age 68.02 years) male patients and 111 female patients (31.71% with mean age 62.92 years) were evaluated with complete follow-up. A total of 470 PTAs were performed on male patients and 213 on female patients in multiple interventions. The majority of patients at the time of treatment were in stage IIb according to the classification of Fontaine (81.6% of male patients and 68% of females). In our sample, peripheral arterial disease stage III and IV according to Fontaine classification occurred twice as frequently in female patients as in male patients (stage III in 12.6% in female versus 6.1% in male, and stage IV in 18% in female versus 8.9% in males). In both groups, the femoral superficialis artery was most frequently dilated (64 cases, 30% in female and 155 cases, 32.9% in male), followed by the iliacal communis artery (46 cases in female and 99 cases in male, both with 21.5%). A balloon angioplasty of the tibialis anterior and posterior arteries was performed twice as frequently in female patients as in male patients (28 cases with 13.1% of tibialis ant. artery in female versus 32 cases with 6.8% in male patients, and in 17 cases with 7.9% of tibialis post. artery in female versus 16 cases with 3.4% in male patients). In this study, without consideration of gender, patency rates of 79% after 2.5 years, 67% after 5 years, 49% after 7.5 years and 37% after 10 years were determined for PTA without stent implantation. Between the 7th and 10th year in follow-up, the cumulative patency rates for stent implantation was 49%, whereas it was 31% for PTA alone. The results of this study show that the stent assisted PTA`s of comm. artery and external iliacal artery are significantly independent of risk factors better than the femoral vessels, and these in female patients better than in male patients. Male patients do not benefit significantly from stent implantation in the long term. As the COXI and II regression analyses show, gender-linked results are most evident for renal insufficiency and diabetes mellitus, and less pronounced also for the number of open lower leg vessels. Conclusion: Under consideration of gender and risk factors, while male patients with diabetes mellitus, renal insufficiency and/or poor run-off did not benefit from stent implantation in the long-term, female patients with similar risk factors showed higher patency rates after stent therapy. In addition, the long-term results after PTA of femoral superficialis artery and poplitea artery are significantly worse than PTA of the pelvic vessels in both genders.

Desmodium adscendens is a rain forest medicinal herb used in managing quite a number of medical conditions. Its efficacy in the treatment of several diseases has made it a first line herb for doctors, especially in managing all forms of spasm. It is however common knowledge that some of these medicinal herbs impact severely on the normal functioning of some vital organs of the body during their administration. The present study was carried out to assess the renal and cardiovascular performance in subjects undergoing treatment with Desmodium adscendens with a view to advising against its indiscriminate use. The parameters used for the assessment of renal functions were serum creatinine and urea concentrations and their clearance. Also, changes in electrolyte concentration of Sodium, Potassium and Chloride concentration were used to assess cardiovascular performance. The histology of the kidney and heart tissues was also done to determine if the extract has impact on the cyto-architecture of the organs. Twenty-four (24) wistar rats were used for the experiment. The rats were grouped randomly into four groups (n = 6). Group 1 served as control, and the rats in the group were given normal rat feeds and water. Group 2 served as low dose group, and rats in this group were administered with low dose of extract 300 mg/kg. Group 3 served as medium group, and rats in this group were treated with medium dose of extract, 450 mg/kg. Group 4 served as high dose group, and rats in this group were treated with high dose of extract 600 mg/kg. The extract was administered for 28 days. Result showed that the extract did not impact negatively on the normal function of the renal and cardiovascular system of the treated groups, rather it enhanced their performances. It can therefore be concluded that the extract is beneficial to renal and cardiovascular functions if used within the treatment dosage. 

Peripartum cardiomyopathy is one of the curable cardiomyopathy. It’s a severe and frequent disease arising among women of childbearing age. Its evolution in the long-term among some patients leads to chronic heart failure. Our study aims to determine from a prospective cohort, the factors associated with the non-recovery of myocardial function upon 12 months of diagnosis. Sociodemographic, clinical and echocardiographic data were collected at the time of diagnosis and then in months 3, 6 and 12. The outcome was the non-recovery of myocardial function at one year, defined by a left ventricular ejection fraction (LVEF) below 50%. 60 patients were analyzed after 12 months of follow-up. Mortality was about 13.3% and recovery rate of myocardial function reached 42.3%. After logistic regression, delay diagnosis and observance were the factors related to non- recovery of myocardial function.

Background: Various surgical methods have been utilized in the management of complete atrioventricular septal defects (CAVSD). Early intervention and achievement of a competent left atrioventricular valve are the key factors for successful treatment. Methods: A total of 66 patients with complete atrioventricular septal defect have been operated in a tertiary care center. Patient group consisted of 28 males and 38 females with an average age of 6.2 ± 3.3 months. Ventricular and atrial defects were repaired generally with single-patch technique using autogenous pericardium. Results: Preoperative catheterization and angiography was performed in 41 patients. Single patch and modified single patch techniques were preferred in 57 and 9 patients respectively. The average duration for respiratory support, intensive care unit stay and discharge from hospital were 36 ± 49.3 hours, 4.1 ± 1.9 days, and 10.1 ± 3.3 days respectively. In the left atrioventricular valve mild, moderate and severe regurgitation were detected in 44 (66.6%), 17 (25.7%) and 2 (3%) patients postoperatively. No regurgitation was determined in 3 patients (4.5%). Two cases ended up with mortality (3%). Conclusion: Single patch repair technique can provide satisfactory surgical outcomes in patients with complete atrioventricular septal defect.

Myocardial infarction without ST segment elevation is one of the most common causes of hospitalization of the elderly patient [1]. Coronarography followed by revascularization, is performed in the vast majority of cases of myocardial infarction without ST segment elevation, in the regions with a well-developed health system. The decision to perform the procedure, the type of approach (early/late) and the selection of the type of myocardial revascularization depend on numerous factors such as: associated comorbidities, clinical presentation, the risk group in which the patient is framed, fragility, cognitive status, life expectancy etc. [2,3]. Older patients often present with various comorbidities, having a higher risk of complications and an unfavorable evolution. Thus, it was observed that invasively treatment is less commonly used in elderly patients with comorbidities, even if, the current guideline recommends that the invasive strategy should be considered in all patients with NSTEMI, regardless of age. At the same time, this subgroup of patients is not so well represented in the studies performed so far, the type of treatment chosen, being most often at the discretion of the attending physician [1,2]. Objective The present study aims to analyze the evolution of a subgroup of patients ≥ 70 years of age, with different comorbidities, with the diagnosis of myocardial infarction without ST segment elevation, according to the type of treatment applied: conservative versus invasive strategy (diagnostic coronarography ± revascularization, if appropriate).

Background: Sudden cardiac death is a major healthcare issue in reduced ejection fraction heart failure (HFrEF) patients. Recently, the new association of sacubitril/valsartan showed a reduction of both ventricular arrhythmias (VA) and mortality even at low dose compared to enalapril in HF patients. The purpose of our study was to assess whether the highest dose of sacubitril/valsartan compared to lower doses may improve the rate of death and VA in a population of patients with HFrEF and with an implantable cardiac defibrillator (ICD). Methods: 104 HF patients with reduced EF under sacubitril/valsartan with an ICD were divided in 2 groups: the first one with the lower doses of sacubitril/valsartan (24/26 mg or 49 mg/51 mg twice daily) and the second with the maximal dose (97mg/103mg twice daily). The primary outcome was a composite of death or appropriate ICD therapy for VA. Results: After a median follow-up of 14 months, 39 patients were treated with lower doses and 65 patients with the highest dose. Patients from the lower doses group were older (70 [60-80] vs. 66 [60-70]; p = 0,03), more symptomatic at initiation (NYHA 3: 44% vs. 19%; p < 0,01) and more often in atrial fibrillation (31% vs. 12%; p = 0,04). The primary composite endpoint occurred in 14 patients (36%) in the low doses group versus 7 patients (11%) in high dose group (p < 0,01). This difference was particularly observed in the subgroup of patients with ischemic cardiomyopathy. In a multivariable analysis, the higher dose was independently associated with the primary outcome with an HR = 2,934 [IC 95% 1,147 – 7,504]; p = 0,03. Kaplan-Meier curve showed an early effect of the highest dose of sacubitril/valsartan association. Conclusion: Patients with HFrEF under the highest dose of sacubitril/valsartan showed better clinical outcomes with a decrease of both mortality or appropriated ICD therapies related to ventricular arrhythmias.

Atherosclerosis is an important promoter of cardiovascular disease potentiating myocardial infarction or stroke. Current demand in biomedical imaging necessitates noninvasive characterization of arterial changes responsible for transition of stable plaque into rupture-prone vulnerable plaque. in vivo contrast enhanced magnetic resonance (MR) imaging (MRI) allows quantitative and functional monitoring of pathomorphological changes through signal differences induced by the contrast agent uptake in the diseased vessel wall, therefore it is the ideal modality toward this goal. However, studies have so far focused on the cellular targets of persisting inflammation, leaving extracellular matrix (ECM) far behind. In this review, we portray ECM remodeling during atherosclerotic plaque progression by summarizing the state of the-art in MRI and current imaging targets. Finally, we aim to discuss glycosaminoglycans (GAGs) and their functional interactions, which might offer potential toward development of novel imaging probes for in vivo contrast-enhanced MRI of atherosclerosis.

Background: Pulmonary vein isolation (PVI) is the accepted standard nowadays for atrial fibrillation (AF) ablation. The most widespread ablation techniques are cryoballoon (CB) and point-by-point radiofrequency (RF) ablation. Comparative studies between both techniques have shown their equivalence for the first ablation procedure, but no trial has explored the potential incremental benefit of crossing over the ablation technique after AF recurrence. Objective: To explore the potential incremental benefit of a crossover ablation strategy for AF recurrences, comparatively with repeating the same ablation energy used for the first procedure. Methods: Retrospective analysis of patients undergoing a second AF ablation procedure after documented AF recurrence. Patients were excluded if all 4 PV were isolated at the beginning of the second procedure or extra-PVI ablation was used for the second procedure. Crossover group (n = 16) included patients in which two different techniques were used for the first and second procedure (CB-RF or RF-CB). Control group (n = 23) for those with same ablation procedure (RF-RF of CB-CB). Acute procedure end-point was PVI of all four pulmonary veins. Patients were followed-up at 3, 6, and 12 months with an electrocardiogram and a 24 h-holter. Arrhythmia-free survival at 1 year after the second ablation procedure was studied, comparing efficiency and safety of the two approaches (crossover vs. same energy). Success was defined as freedom from AF or atrial tachycardia lasting > 30 s off antiarrhythmic drugs (AADs) Results: A cohort of 39 paroxysmal and persistent AF patients was analyzed. PVI after the second procedure was 100% in all patients in both groups. There were no baseline relevant differences between the two groups. No deaths or hospitalizations occurred during follow up (data censored at 24h moths). At 1 year, arrhythmia free-survival was significantly higher in the crossover group compared to control group [93,3% vs. 47,8%; HR 0.19 (0.06-0.66);p = 0,009]. Conclusion: Crossing the ablation technique (point-by-point radiofrequency or cryoballoon PVI) after AF recurrence significantly improved arrhythmia free-survival at one year, despite no difference in acute success (PVI isolation). Randomized controlled trials with a higher amount of patients are needed to confirm the results and widespread this approach.

Implantable cardioverter defibrillators (ICDs) are electronic devices that can prevent sudden cardiac death (SCD) caused by arrhythmic events in patients. The latest ESC/EAS and ACC/AHA Guidelines deem the placement of an ICDs appropriate in patients with heart failure class NYHA II and III in the presence of an ejection fraction less than or equal to 35% [1,2]. ICDs are usually not indicated in either class I or IV patients. The Guidelines recommendations for primary prevention of SCD with ICD implantation do not take into account the age of the patients but only their life expectancy which must be at least 1 year. Our patients usually are over eighty years old with heart failure and severely reduced ejection fraction. We must consequently decide if it is right to implant these patients with an ICD. Is the use of ICD in the patients over 80, in particular over 90 years old, really make sense becomes particularly important considering demographic changes that await us in the coming decades.