Objectives This study aimed to determine whether post-conditioning at the time of percutaneous coronary intervention could reduce reperfusion-induced myocardial edema in patients with acute ...ST-segment elevation myocardial infarction (STEMI). Background Myocardial edema is a reperfusion injury with potentially severe consequences. Post-conditioning is a cardioprotective therapy that reduces infarct size after reperfusion, but no previous studies have analyzed the impact of this strategy on reperfusion-induced myocardial edema in humans. Methods Fifty patients with STEMI were randomly assigned to either a control or post-conditioned group. Cardiac magnetic resonance imaging was performed within 48 to 72 h after admission. Myocardial edema was measured by T2-weighted sequences, and infarct size was determined by late gadolinium enhancement sequences and creatine kinase release. Results The post-conditioned and control groups were similar with respect to ischemia time, the size of the area at risk, and the ejection fraction before percutaneous coronary intervention. As expected, post-conditioning was associated with smaller infarct size (13 ± 7 g/m2 vs. 21 ± 14 g/m2 ; p = 0.01) and creatine kinase peak serum level (median interquartile range: 1,695 1,118 to 3,692 IU/l vs. 3,505 2,307 to 4,929 IU/l; p = 0.003). At reperfusion, the extent of myocardial edema was significantly reduced in the post-conditioned group as compared with the control group (23 ± 16 g/m2 vs. 34 ± 18 g/m2 ; p = 0.03); the relative increase in T2W signal intensity was also significantly lower (p = 0.02). This protective effect was confirmed after adjustment for the size of the area at risk. Conclusions This randomized study demonstrated that post-conditioning reduced infarct size and edema in patients with reperfused STEMI. (Post Cond No Reflow; NCT01208727 )
Objectives This study examined the effect of a single dose of cyclosporine administered at the time of reperfusion on left ventricular (LV) remodeling and function by cardiac magnetic resonance 5 ...days and 6 months after myocardial infarction. Background In a human study, administration of cyclosporine at the time of acute reperfusion was associated with a smaller infarct size. Methods Twenty-eight patients of the original cyclosporine study had an acute (at 5 days) and a follow-up (at 6 months) cardiac magnetic resonance study to determine LV volumes, mass, ejection fraction, myocardial wall thickness in infarcted and remote noninfarcted myocardium, and infarct size. Results There was a persistent reduction in infarct size at 6 months in the cyclosporine group compared with the control group of patients (29 ± 15 g vs. 38 ± 14 g; p = 0.04). There was a significant reduction of LV end-systolic volume (and a trend for LV end-diastolic volume; p = 0.07) in the cyclosporine group compared with the control group, both at 5 days and 6 months after infarction. There was no significant difference between the 2 groups in either global LV mass or regional wall thickness of the remote noninfarcted myocardium at 5 days or 6 months. Attenuation of LV dilation and improvement of LV ejection fraction by cyclosporine at 6 months were correlated with infarct size reduction. Conclusions Cyclosporine used at the moment of acute myocardial infarction reperfusion persistently reduces infarct size and does not have a detrimental effect on LV remodeling. These results are preliminary and must be supported by further studies. (Ciclosporin A and Acute Myocardial Infarction; NCT00403728 )
Early infarct-related artery (IRA) patency is associated with better clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). Using the French Registry of ST-elevation and ...non–ST-elevation Myocardial Infarction (FAST-MI) 2010 registry, we investigated factors related to IRA patency (thrombolysis in myocardial infarction TIMI 2/3 flow) at the start of procedure in patients admitted for primary percutaneous coronary intervention. FAST-MI 2010 is a nationwide French registry including 4,169 patients with acute MI. Of 1,452 patients with STEMI with primary percutaneous coronary intervention, 466 (32%) had TIMI 2/3 flow of IRA before the procedure. Mean age (62 ± 14 years in both groups), Global Registry of Acute Coronary Event score (141 ± 31 vs 142 ± 34), and time from onset to angiography (472 ± 499 vs 451 ± 479 minutes) did not differ according to IRA patency (TIMI 2/3 vs TIMI 0/1). Using multivariate logistic regression analysis, IRA patency was more frequently found in patients having called earlier (time from onset to electrocardiogram ECG <120 minutes; odds ratio OR 1.49; 95% confidence interval CI 1.17 to 1.89), or receiving rapid-onset of action (prasugrel or glycoprotein IIb-IIIa) antiplatelet therapy in the prehospital setting (OR 1.59, 95% CI 1.14 to 2.21). Increasing time from diagnostic ECG to angiography was also associated with IRA patency (>90 minutes; OR 1.37, 95% CI 1.08 to 1.75). In conclusion, preprocedural IRA patency is observed in one third of patients with STEMI, it is more frequently found in patients having received fast-acting antiplatelet therapy before angiography, and in patients having called early. Higher IRA patency with increasing time delays from qualifying ECG to angiography suggests an additional role of spontaneous or medication-mediated fibrinolysis.
Recent studies have shown that the decrease in ventricular septal rupture (VSR) incidence after acute myocardial infarction is related to the improvement of reperfusion strategies. Our main objective ...was to explore the influence of therapeutic management changes on post-infarct VSR patient outcomes in a single reference center over a period of 30 years. We analyzed therapeutic management strategies and mortality rates in 228 patients with VSR after acute myocardial infarction admitted from 1981 to 2010. Patients were classified in 3 successive decades. There were no significant differences in clinical characteristics of patients with VSR at admission among those decades. Overall, surgery was performed in 159 patients (71.9%), primary transcatheter VSR closure was attempted in 5 patients (2.2%), and 64 patients (27.6%) were managed medically. Independent predictors of in-hospital mortality were VSR surgical repair (odds ratio OR 0.22, 95% confidence interval CI 0.1 to 0.7, p = 0.008), cardiogenic shock (OR 6.06, 95% CI 2.8 to 13.1, p <0.0001), and Killip class on admission (OR 1.75, 95% CI 1.1 to 9.9, p = 0.02). We found a significant 1-year mortality reduction between the first and second decades (hazard ratio 0.48, 95% CI 0.28 to 0.80; p = 0.005), with no significant change in the last decade (p = 0.2). This change was related to a systematic referral to surgical repair and shorter delays to VSR surgery (5.2 ± 6.3 vs 1.9 ± 3.2 days from first to second decade; p = 0.012). In conclusion, surgical repair remains the only significant efficient therapy to reduce mortality in patients with VSR (p <10−3 ). In-hospital prognosis remains disappointing. This contrasts with the favorable long-term outcome of patients who survive the perioperative period and are discharged from hospital.
Abstract Objective The influence of initial-thrombolysis in myocardial infarction (i-TIMI) coronary flow in the culprit coronary artery on myocardial infarct and microvascular obstruction (MVO) size ...is unclear. We assessed the impact on infarct size of i-TIMI flow in the culprit coronary artery, as well as on MVO incidence and size, by contrast-enhanced cardiac magnetic resonance (ce-CMR). Methods In a prospective, multicenter study, pre-percutaneous coronary intervention (PCI) coronary occlusion was defined by an i-TIMI flow ≤1, and patency was defined by an i-TIMI flow ≥2. Infarct size, as well as MVO presence and size, were measured on ce-CMR 72 h after admission. Results A total of 140 patients presenting with ST-elevated myocardial infarction referred for primary PCI were included. There was no significant difference in final post-PCI TIMI flow between the groups (2.95 ± 0.02 vs. 2.97 ± 0.02, respectively; p = 0.44). In the i-TIMI flow ≤1 group, infarct size was significantly larger (32 ± 17 g vs. 21 ± 17 g, respectively; p = 0.002), MVO was significantly more frequent (74% vs. 53%, respectively; p = 0.012), and MVO size was significantly larger 1.3 IQR (0; 7.1) vs. 0 IQR (0; 1.6), compared to in the i-TIMI ≥2 patient group. Conclusion Initial angiographic TIMI flow in the culprit coronary artery prior to any PCI predicted final infarct size and MVO size: the better was the i-TIMI flow, the smaller were the infarct and MVO size.
Abstract Introduction The aim of this study was to evaluate bioimpedance vector analysis (BIVA) for the diagnosis of acute heart failure (AHF) in patients presenting with acute dyspnea to the ...emergency department (ED). Methods Patients with acute dyspnea presenting to the ED were prospectively enrolled. Four parameters were assessed: resistance (R), reactance (Ra), total body water (TBW), and extracellular body water (EBW). Brain natriuretic peptide (BNP) measures and cardiac ultrasound studies were performed in all patients at admission. Patients were classified into AHF and non-AHF groups retrospectively by expert cardiologists. Results Seventy-seven patients (39 men; age, 68 ± 14 years; weight, 79.8 ± 20.6 kg) were included. Of the 4 BIVA parameters, Ra was significantly lower in the AHF compared to non-AHF group (32.7 ± 14.3 vs 45.4 ± 19.7; P < .001). Brain natriuretic peptide levels were significantly higher in the AHF group (1050.3 ± 989 vs 148.7 ± 181.1 ng/L; P < .001). Reactance levels were significantly correlated to BNP levels ( r = − 0.5; P < .001). Patients with different mitral valve Doppler profiles (E/e’ ≤ 8, E/e’ ≥ 9 and < 15, and E/e’ ≥ 15) had significant differences in Ra values (47.9 ± 19.9, 34.7 ± 19.4, and 31.2 ± 11.7, respectively; P = .003). Overall, the sensitivity of BIVA for AHF diagnosis with a Ra cutoff at 39 Ω was 67% with a specificity of 76% and an area under the curve at 0.76. However, Ra did not significantly improve the area under the curve of BNP for the diagnosis of AHF ( P = not significant). Conclusion In a population of patients presenting to the ED with dyspnea, BIVA was significantly related to the AHF status but did not improve the diagnostic performance for AHF in addition to BNP alone.
Churg–Strauss syndrome (CSS) is a multisystem disorder characterised by asthma, prominent peripheral blood eosinophilia, and vasculitis signs. We report the case of a 22 year-old man admitted to the ...intensive care unit for acute myocarditis complicated with cardiogenic shock. Eosinophilia, history of asthma, lung infiltrates, paranasal sinusitis, glomerulonephritis, and abdominal pain suggested the diagnosis of CSS. Cardiac MRI confirmed cardiac involvement with a diffuse subendocardial delayed enhancement of the left ventricular wall, and a left ventricular ejection fraction (LVEF) of 30%. Acute myocarditis was confirmed with myocardial biopsy. The patient was successfully treated with systemic corticosteroids, intravenous cyclophosphamide, vasopressor inotropes, intra-aortic balloon pump and mechanical ventilation, and was discharged 21 days later. One year after diagnosis, the patient was asymptomatic. The eosinophilic cell count was normal. Follow-up MRI at one year showed LVEF of 40% with persistent delayed enhancement. Cardiac involvement by CSS requires immediate therapy with corticosteroids and cyclophosphamide, which may allow recovery of the cardiac function.
As a ventricular unloading catheter, the Impella Recover LP 5.0 (Abiomed, Danvers, MA) is appropriate for temporary circulatory assistance in severe left ventricular dysfunction. We describe a new ...implantation approach to the right axillary artery with the aims of avoiding vascular problems due to atherosclerosis of the peripheral arteries and improving patient mobility and rehabilitation during mechanical support.
A 42 year-old patient presented with circulatory failure and lactic acidosis. Clinical features, later coupled with biological tests, led to the diagnosis of wet beriberi syndrome and scurvy. ...Echocardiography showed a pattern of thiamine deficiency with high cardiac output and low vascular resistance. The patient's condition and biological parameters immediately improved after treatment injections of thiamine. Wet BeriBeri is often overlooked in western countries and is a diagnosis that must be considered based on history, and clinical and echocardiographical findings. Résumé: Un patient âgé de 42 ans a présenté une insuffisance circulatoire et une acidose lactique. Ses caractéristiques cliniques et les résultats de laboratoire obtenus ultérieurement ont mené au diagnostic de béribéri humide et de scorbut. Une échocardiographie a révélé un profil indiquant une carence en thiamine accompagnée d’un débit cardiaque élevé et d’une faible résistance vasculaire. L’état et les paramètres biologiques du patient se sont améliorés immédiatement après l’administration de thiamine par injection. Le diagnostic de béribéri humide est souvent négligé dans les pays occidentaux, mais il faut en tenir compte en présence des signes appropriés : antécédents du patient, observations cliniques et résultats à l’échocardiographie.
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