Readjustment of antithrombotic therapy in stroke-patients owing to transesophageal echocardiography findings
Published on: 26th November, 2019
OCLC Number/Unique Identifier: 8440612661
Objectives: Cardioembolic etiology is a frequent source of ischemic stroke. Echocardiogram is the mainstay of cardioembolic source detection with regard to plan secondary stroke management, however it remains unclear how often clinically actionable findings are provided hereby. In addition, it is uncertain whether echocardiography should be performed transthoracic or transesophageal (TEE). In a monocenter study, we evaluated the frequency of pathological findings from TEE evaluation in patients with ischemic stroke with suspected cardioembolic and cryptogenic source and determined whether there was an associated adjustment in the prescribed administration of antithrombotic therapy.
Materials and Methods: Over a 21-month period (2012-2013), we enrolled 143 patients in a prospective monocenter study (mean age ± standard deviation, 70 ± 12 years; females, 44.1%) who were admitted to the Department of Neurology at the University of Lübeck due to ischemic stroke and who underwent TEE due to supposed cardiac embolism. We assessed the presence of atrial fibrillation; days from admission to TEE; and TEE findings, including atrial septal aneurysm, thrombogenic aortic arch, valve failure, presence of left atrial thrombus, and patent foramen ovale. Demografic information and medical history were drawn from patient records and the hospital information system.
Results: On average, TEE was performed 4 days after admission to the hospital. Left atrial thrombus was detected in 3 patients (2.1%), patent foramen ovale (PFO) in 27 (18.9%), atrial septum aneurysm in 17 (11.9%), and thrombogenic aortic arch in 29 (20.3%). Findings from TEE were commonly associated with therapeutic adjustment; antiplatelet therapy increased from 30.1% to 80.4%, oral anticoagulation therapy increased from 2.8% to 27.3%.
Conclusion: Findings from TEE for the evaluation of ischemic stroke lead to frequent adjustment of prior antithrombotic therapy, antiplatelet as well as anticoagulation.
Long-Term Impact of Coronary Artery Disease in Lung Transplantation
Published on: 26th November, 2019
OCLC Number/Unique Identifier: 8440605468
Background: Adoption of the Lung Allocation Score (LAS) has led to increased listing of older patients and those with idiopathic pulmonary fibrosis (IPF) for lung transplantation (LTX). Older patients and those with IPF have higher prevalence of coronary artery disease (CAD), a relative contraindication for LTX. The impact of the LAS on CAD prevalence and cardiovascular morbidity in LTX recipients is unknown.
Methods: Retrospective review of single institution database from January 2000 to December 2010. Patients with and without CAD were compared by age, gender, LAS, single vs double LTX, and transplant indication. Survival was calculated by Kaplan-Meier method, and statistical significance determined by log-rank method. Survival analysis was performed on all patients and by 3:1 propensity matching. Differences in CAD, gender, and indication were determined by Chi-squared test. Differences in LAS and age were calculated with a two-tailed t - test.
Results: In the pre-LAS era, 6.2% (9/145) recipients had CAD vs. 9.2% (17/184) in the post-LAS era (p = 0.411). Among all patients, recipients with CAD had a worse long term survival as estimated by Kaplan-Meier method (p = 0.001), although there was no statistically significant difference after propensity matching ((p = 0.14). Although more recipients in the post-LAS era had a diagnosis of IPF [15/145 vs. 71/184 patients, (p < 0.001)], there was no difference in the prevalence of CAD in the IPF cohort compared to others. There were no differences in cardiovascular deaths among recipients with CAD, with IPF, or in the post-LAS era. Patients with a pre-transplant diagnosis of CAD had an descreased risk of new onset postoperative atrial fibrillation (AF) (p = 0.007; HR:0.133; CI:0.030-0.583).
Conclusion: Adoption of the LAS was not associated with a significant change in proportion of recipients with CAD who underwent LTX at our institution, despite an increase in recipients with IPF. Recipients with CAD had a higher risk of developing new postoperative AF and worse survival than patients without CAD. Differences in survival, however, could not be attributed directly to CAD based on propensity matched analysis
Aortic dissection causing 2 myocardial infarctions
Published on: 16th December, 2019
OCLC Number/Unique Identifier: 8488779776
A 56-year-old man was admitted to our hospital because of sudden onset of right-sided thoracic pain. The ECG showed inferior ST segment elevations. He has been treated with aspirin, clopidogrel, unfractionated heparin and tenecteplase, and his symptoms resolved after 30 minutes. About half an hour later, the patient developed again left-sided thoracic pain and the signs of an anterior myocardial ST-segment elevation infarction. 90 minutes after receiving the initial medications, the performed coronary angiography revealed a long dissection of a large ramus circumflexus. Furthermore, the left anterior descending coronary artery was occluded at about the mid-level. The left ventriculography showed a reduced ventricular function and a Stanford type A aortic dissection. Immediate patient transfer for emergency surgical intervention was arranged. However, ventricular fibrillation occurred during transport and he required endotracheal intubation and prolonged cardiopulmonary resuscitation. Unfortunately, he died during further transport.
In a patient with massive thoracic pain of initially uncommon localization in combination with fluctuation of ST-segment elevations, aortic dissection should be seriously taken into the differential diagnosis as well as into therapeutic management decisions (in particular antiplatelet and thrombolytic therapy).
Evaluation of the effect of coronary artery bypass grafting on the right ventricular function using speckle tracking echocardiography
Published on: 30th December, 2019
Purpose: This was a prospective study conducted at Benha University hospital and National Heart Institute on one hundred patients undwent coronary artery bypass grafting (CABG) to evaluate the effect of CABG on the right ventricular (RV) function using speckle tracking echocardiography (STE).
Methods: All cases were subjected to detailed medical history, full physical examination, 12 leads electrocardiogram (ECG), routine laboratory tests including (complete blood picture, liver functions, renal functions and lipid profile) and echocardiography either conventional echocardiography or STE, all parameters obtained before and within 2 weeks after surgery.
Results: By conventional echocardiography there was statistically significant decrease in peak right ventricle systolic velociy (RVS) from (12.76 ± 1.72) to (7.33 ± 1.71) and tricuspid annular plane systolic excursion (TAPSE) from (22.8 ± 3.99) to (13.77 ± 4.63) among the studied patients after CABG. While there was significant increase in right ventricle fractional area change (RVFAC) from (44.69 ± 3.25) to (49.01 ± 3.36). On the other hand, there was non-significant change in right ventricle end diastolic diameter (RVEDD) at mid-cavity from (26.37 ± 2.72) to (26.53 ± 2.72) and basal segment from (36.05 ± 2.98) to (36.29 ± 3.04), right ventricle stroke volume (RVSV) from (65.44 ± 7.02) to (65.85 ± 6.86) and right myocardial performance index (RMPI) from (0.491 ± 0.088) to (0.498 ± 0.086).
By STE There was statistically significant decrease in right ventricle global longitudinal strain (RVGLS) from (-20.63 to -14.1) after CABG. There was statistically significant decrease in right ventricle free wall longitudinal strain [apical decreased from (-23.73 to -13.7), mid-cavity decreased from (-25.76 to -11.53), basal decreased from (-20.39 to -10.13) and lateral wall declined from (-23.01 to -9.13)]. There was statistically significant decrease in interventricular septum longitudinal strain [apical decreased from (-19.77 to -10.06), mid-cavity decreased from (-17.81 to -10.87) and basal decreased from (-15.89 to -11.13)]. There was statistically significant increase in RV circumferential strain of lateral free wall from (-12.04 to -16.21), while there was non-significant change in RV circumferential strain of septum from (-19.77 ± 4.86) to (-20.37 ± 5.14).
Conclusion: Distorted RV geometry after CABG can lead to altered deformation parameters, in other words longitudinal functional parameters may underestimate RV function and the decrease in RVGLS was compensated by increase in circumferential strain of lateral free wall of RV without change in RVSV or RMPI. Therefor changes in deformation parameters should always be interpreted in relation to change in geometry.
A proposed mechanism to explain increases in intracranial pressure: The concept of cerebral artery wedge pressure
Published on: 8th January, 2020
OCLC Number/Unique Identifier: 8514665738
We hypothesize that, with elevated cerebral spinal fluid (CSF) pressure, cerebral micro-vascular obstruction and congestion may occur despite (subdural) large-vein pressures being normal. Smaller veins emptying into these larger, dura-enveloped veins are not immune to the compressive effects of elevated CSF pressure and a “Starling Resistor” mechanism might explain why elevated CSF pressures collapse these smaller veins. This small cerebral venous starling resistor compression mechanism may be the final common pathway for many patients suffering from increased CSF pressures and might also be an important contributor to impaired focal venous drainage presenting as a headache with normal venous sinus pressures.
Effect of hemodialysis session on acute changes in inflammatory and cardiovascular risk biomarkers
Published on: 9th January, 2020
OCLC Number/Unique Identifier: 9269418657
Background: Inflammation is associated with enhanced cardiovascular risk profile and increased cardiovascular mortality in end-stage kidney disease patients undergoing hemodialysis. Mechanisms of activated acute phase reaction in patients on chronic hemodialysis remain to be identified. As successful treatment of the inflammatory condition in these patients may improve long-term survival, we studied potential changes in different inflammatory biomarkers of cardiovascular risk in end-stage kidney disease patients after a mid-week hemodialysis session.
Methods: Inflammatory biomarkers of cardiovascular risk (cystatin-C, homocysteine, C-reactive protein, procalcitonin, pentraxin-3, serum amyloid-A) and atherogenic plasma lipoproteins (Lipoprotein(a), cholesterol low and high density lipoproteins) were studied in 21 end-stage kidney disease patients previously and after a mid-week hemodialysis session.
Results: We found a significant reduction in serum levels of low molecular weight molecules: cystatin-C (5.56 to 1.85 mg/L, 66.73%, p < 0.001), homocysteine (22.85 to 13.25 µmol/L, 42.01%, p < 0.001) and procalcitonin (0.788 to 0.457 ng/mL, 42.01%, p < 0.001). Large molecules as C-reactive protein (9.70 to 9.90 mg/L, 2.06%, p = 0.022) and pentraxin-3 (1.67 to 4.28 ng/mL, 156%, p < 0.001) increased, but serum amyloid-A decreased (15.90 to 12.70 mg/L, 20.13%, p < 0.05). There was no change in Lipoprotein (a) levels.
Conclusion: Pentraxin-3 was a more specific inflammatory vascular marker than C-reactive protein, and the best inflammatory marker associated with hemodialysis. Homocysteine, procalcitonin and the other small proteins could be released and removed during hemodialysis session. Further studies are needed to understand the behavior and significance of these markers after successive hemodialysis.
Coronary-intercostal steal syndrome, a rare connection between the left circumflex coronary artery and intercostal arteries: A case report
Published on: 13th January, 2020
OCLC Number/Unique Identifier: 8514666304
A 60-year-old female patient presented with typical anginal pain on exertion and relieved by rest for about one month. Percutaneous coronary angiography was done and showed an abnormal left circumflex coronary artery connecting to intercostal artery. Embolization of that abnormal connection was done successfully and the patient discharged from hospital after 24 hours. This case shows a new form of coronary steal syndrome. This cause could be missed if not put under the differential diagnosis of typical anginal pain with normal coronary arteries.
Occluded superior vena cava and failed epicardial pacing: An unorthodox solution
Published on: 13th January, 2020
OCLC Number/Unique Identifier: 8514668207
Permanent pacemaker implantation is conventionally done via upper limb veins. But in 1% - 6% cases, usual sub clavicular approach is either not possible or contraindicated due to complete occlusion of superior vena cava (SVC) or bilateral subclavian vein and/or bilateral implant site infection or thin skin [1]. Alternative approaches are warranted, including leadless pacemaker or complex lead extraction techniques, before considering surgical epicardial lead placement as a last resort because it has own hazards. We report a patient with complete heart block, total SVC obstruction, and a previously implanted malfunctioning epicardial lead presenting with pacemaker end of life. In view of exhaustion of the surgical option and in a resource constrained situation for lead extraction or leadless pacemaker, transiliac endocardial pacemaker implantation was done and a repeat surgery was averted.
Learning objective: Complete venous occlusion is not very often encountered after pacemaker/ICD implantation. Apart from the risk of general anesthesia and invasive surgery, epicardial leads increase battery drain, and have a shorter operating life compared to an endocardial lead. The sparingly utilized iliac venous approach for permanent pacemaker implantation is a valuable, safe and minimally invasive alternative, when the conventional percutaneous access is unavailable, and surgery is undesirable or not possible.
Gender-specific associations of anthropometric measures of adiposity with blood pressure and hypertension in young Chinese Medical College Students
Published on: 31st January, 2020
OCLC Number/Unique Identifier: 8535882054
Purpose: There are uncertainties about whether general or central obesity is the more important determinant for blood pressure and hypertension in young Chinese. We aim to investigate the association between adiposity measures and blood pressure and hypertension in young medical students.
Methods: A total of 380 medical students were recruited from the 2012 batch in the Clinical College of Dali University. Anthropometric measures and office blood pressure were measured. Blood pressure status was defined by Chinese hypertension guidelines and ACC/AHA 2017 hypertension guidelines, respectively. We examined the associations of adiposity measures (body weight, body mass index [BMI], waist circumference, hip circumference, waist-to-hip ratio [WHR], waist-to-height ratio [WHtR], ponderal index [PI], body adiposity index (BAI) and conicity index [CI]) with blood pressure and hypertension by sex.
Results: In 380 subjects (women 66.6%, mean age 21.5 years), the prevalence of obesity (BMI ≥ 28 kg/m2) was 2.1%, and the prevalence of hypertension was 2.6% (≥ 140/90 mmHg) and 24.5% (≥ 130/80 mmHg), respectively. In correlation analyses and multivariable-adjusted linear regression analyses, most adiposity measures of central obesity were significantly associated with blood pressure in men, while in women, either adiposity measures of central or general obesity were associated with blood pressure. The predictive power of adiposity measures for hypertension was generally low in men. However, adiposity measures of either general obesity or central obesity were predictive for hypertension defined by Chinese hypertension guidelines in women.
Conclusion: There are gender-specific associations of central and general obesity with blood pressure and hypertension in young Chinese medical students.
Localization of the occluded vessel in acute myocardial infarction
Published on: 18th February, 2020
OCLC Number/Unique Identifier: 8550958571
This is a review of features in ECG to diagnose the culprit artery responsible for the infarction. Localization of the occluded vessel in acute myocardial infarction is important for many reasons: to know which artery is to dilate and stent; to assess the severity of the lesion; to compare with the echocardiographic area with hypokinesia or akinesia and to differentiate the recent from the old occluded vessel. The ST-segment changes in 12-lead ECG form the basis of diagnosis, management, and prognosis.
ECG interpretation and commentary
Published on: 18th February, 2020
OCLC Number/Unique Identifier: 8550965055
This is demonstration of selected ECGs for learning or for exams; guided by lessons from great teachers as Prof. Hein Wellens MD. Here we provide advanced examples with comment and analysis.
His bundle pacing in heart failure: A review of current literature
Published on: 3rd March, 2020
OCLC Number/Unique Identifier: 8560715663
Biventricular (BiV) pacing revolutionized the heart failure management in patients with sinus rhythm and left bundle branch block; however, left ventricular-lead placement is not always technically possible. Also, BiV pacing does not fully normalize ventricular activation and, therefore, the ventricular resynchronization is imperfect. On the other hand, right ventricular pacing for bradycardia may cause or worsen heart failure in some patients by causing dyssynchronous ventricular activation. His bundle pacing comes as an alternative to current approaches as it activates the ventricles via the native His-Purkinje system, resulting in true physiological pacing, and, therefore, is a promising site for pacing in bradycardia and traditional CRT indications in cases where it can overcome left bundle branch block. Furthermore, it has the potential to open up new indications for pacing therapy in heart failure, such as targeting patients with PR prolongation, but a narrow QRS duration. In this article we explore the history, clinical evidence, proposed mechanisms, procedural characteristics, and the role in current therapy of His bundle pacing in the prevention and treatment of heart failure.
Pathological left ventricular hypertrophy and outflow tract obstruction in an infant of a diabetic mother: A case report
Published on: 3rd March, 2020
OCLC Number/Unique Identifier: 8560717043
Background: Infants of diabetic mothers (IDMs) are at increased risk of developing congenital anomalies including cardiac defects. Pathological left ventricular hypertrophy, asymmetrical septal hypertrophy and outflow tract obstruction is a rare but known cardiac comorbidity in infants of diabetic mothers. The severity of this condition in IDMs can vary from an incidental finding on echocardiography to an infant with severe symptoms of congestive heart failure and specific management of the condition varies.
Aim: The aim of this article is to report this clinical entity in a Nigerian infant born to a mother with poor glycaemic control in pregnancy and highlight management.
Case report: We report a term neonate who was diagnosed as a case of pathological left ventricular hypertrophy, asymmetrical septal hypertrophy and outflow tract obstruction delivered to a mother with gestational diabetics with poor glycaemic control in pregnancy. Child was treated successfully with β-adrenergic blocker and showed resolution of hypertrophy in follow-up echocardiography.
Conclusion: Infants of diabetic mothers are very high risk infants. Pathological left ventricular hypertrophy in IDM have good prognosis. Early recognition and prompt intervention is advocated.
Clinical relevance linked to echocardiography diagnosis in Bland, White and Garland syndrome
Published on: 6th March, 2020
OCLC Number/Unique Identifier: 8560715071
Introduction: Bland, White and Garland syndrome is a coronary anomaly with high mortality without treatment. Its clinical presentation is varied which makes epidemiological documentation difficult. Echocardiography is a useful non-invasive tool for diagnosis.
Objective: To determine the echocardiographic variables that lead to the diagnosis of Bland, White and Garland syndrome and their clinical relevance.
Material: Observational, prospective and cross-sectional study in 31 patients of the “William Soler” Pediatric Cardiocenter, from 2005 to 2018. To check the association of echocardiographic variables with the diagnosis of Bland, White and Garland syndrome, an effectiveness study was carried out that included the analysis of the incidence of echocardiographic variables that lead to the diagnosis of this entity. The clinical relevance was estimated according to the minimum importance limit. The statistical validation of the research results adopted a significance level of less than 5% (p < 0.05).
Results: The variables that facilitate the echocardiographic diagnosis of Bland, White and Garland syndrome were the echocardiographic visualization of the anomalous connection and the reversed flow in the anomalous left coronary artery. These echocardiographic measures have clinical relevance according to the quantification of risk estimators (incidence) the echocardiographic visualization of the anomalous connection, RR 39.00 and the reversed flow in the anomalous coronary artery, RR 26.31. LIM´s calculation value amounted to 6.31 and coincided with the risk estimators (incidence).
Conclusion: The echocardiographic visualization of the anomalous origin of the left coronary artery from the pulmonary arterial trunk and the detection of the local intracoronary reversed flow instituted as factors to be considered for the effective diagnosis of the disease. The documentation of the diagnostic aspects of the syndrome through echocardiography contains high statistical value and clinical relevance.
Dapt Review
Published on: 25th March, 2020
OCLC Number/Unique Identifier: 8576364795
Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y12 receptor inhibitor has been consistently shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy but at the expense of an increased risk of significant bleeding. Among patients with stable CAD undergoing PCI with drug-eluting stents (DES), shorter duration of DAPT (3–6 months) were shown non-inferior to 12 or 24 months duration concerning MACE but reduced the rates of major bleeding? Contrariwise, prolonged DAPT durations (18–48 months) reduced the incidence of myocardial infarction and stent thrombosis, but at the cost of an increased risk of majör bleeding and all-cause mortality. Until more evidence becomes available, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation, baseline risk profile and management strategy. Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. This article provides a contemporary state-of-the-art review of the current evidence on DAPT for secondary prevention of patients with CAD and its future perspectives.
Primary prevention of SCD with ICD in the elderly
Published on: 30th March, 2020
OCLC Number/Unique Identifier: 8576353351
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.
Recurrence of atrial fibrillation after pulmonary vein isolation, should we change the energy and technique?
Published on: 3rd April, 2020
OCLC Number/Unique Identifier: 8576354289
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.
Effects of highest dose of sacubitril/valsartan association compared to lower doses on mortality and ventricular arrhythmias
Published on: 24th April, 2020
OCLC Number/Unique Identifier: 8588720714
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.
Conservative treatment versus invasive approach in elderly patients with myocardial infarction without ST-segment elevation
Published on: 30th April, 2020
OCLC Number/Unique Identifier: 8588723372
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).
Our experience with single patch repair of complete atrioventricular septal defects
Published on: 2nd May, 2020
OCLC Number/Unique Identifier: 8588716552
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.
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