We sought to determine acute and chronic efficacy of a percutaneous mitral annuloplasty (PMA) device in experimental heart failure (HF). Further, we evaluated the potential for adverse effects on ...left ventricular (LV) function and coronary perfusion.
Reduction of mitral annular dimension with a PMA device in the coronary sinus may reduce functional mitral regurgitation (MR) in advanced HF.
Study 1: a PMA device was placed acutely in anesthetized open-chest dogs with rapid pacing-induced HF (n = 6) instrumented for pressure volume analysis. Study 2: in 12 anesthetized dogs with HF, fluoroscopic-guided PMA was performed, and dogs were followed for four weeks with continuing rapid pacing.
Study 1: percutaneous mitral annuloplasty reduced annular dimension and severity of MR at baseline and with phenylephrine infusion to increase afterload (MR jet/left atrial LA area 26 ± 1% to 7 ± 2%, p < 0.05). Pressure volume analysis demonstrated no acute impairment of LV function. Study 2: no device was placed in two dogs because of prototype size limitations. Attempted PMA impaired coronary flow in three dogs. Percutaneous mitral annuloplasty (n = 7) acutely reduced MR (MR jet/LA area 43 ± 4% to 8 ± 5%, p < 0.0001), regurgitant volume (14.7 ± 2.1 ml to 3.1 ± 0.5 ml, p < 0.05), effective regurgitant orifice area (0.130 ± 0.010 cm2to 0.040 ± 0.003 cm2, p < 0.05), and angiographic MR grade (2.8 ± 0.3 device to 1.0 ± 0.3 device, p < 0.001). In the conscious state, MR was reduced at four weeks after PMA (MR jet/LA area 33 ± 3% HF baseline vs. 11 ± 4% four weeks after device, p < 0.05)
Percutaneous mitral annuloplasty results in acute and chronic reduction of functional MR in experimental HF.
We report a case of posttraumatic meningitis due to Mycobacterium abscessus, treated initially with oral clarithromycin and intravenous amikacin plus intrathecal amikacin. Despite cerebrospinal fluid ...(CSF) levels of clarithromycin and amikacin in excess of their in vitro minimum inhibitory concentrations for the organism, the CSF cultures remained continuously positive for M. abscessus. To our knowledge, this is the first documented case of M. abscessus meningitis and the first report of measured CSF levels of clarithromycin in a patient with meningitis, showing that even therapeutic CSF levels of clarithromycin and amikacin might not be successful in eradicating M. abscessus meningitis.
...the initial goal of measure 1 (comprehensive documentation of indications for PCI) and measure 2 (appropriate indication for elective PCI) is to ensure that adequate information for assessing the ...indication for revascularization procedures is captured and reported, so that continued evaluation and feedback to improve both the AUC ratings and clinical care can occur.4.1.2 Patient Education/Shared Decision-Making Measures Although the aforementioned factors highlight the difficulty of determining when PCI is clinically indicated, reaching a high-quality decision goes beyond meeting the AUC. ...it was recognized that rigorous, standardized anginal class assessment (e.g., the Seattle Angina Questionnaire), though standard in clinical trials, is not typically performed in the clinical setting, and that more common systems, like the Canadian Classification System, have poor reliability and are too subjective. ...evidence indicates that doses are inconsistently documented. ...although this measure is expected to have limited impact because it requires only documentation, it is an intermediate step to a more meaningful performance measure.Radiation Dose Documented‡2,3,41There are few potential unintended consequences given that there are no thresholds specified in this measure. ...evidence indicates that doses are inconsistently documented. ...although this measure is expected to have limited impact because it requires only documentation, it is an intermediate step to a more meaningful performance measure.Postprocedural Optimal Medical Therapy Composite†1,2,3,4Registry data are currently limited, making it unfeasible to capture specific medical, patient, or system exceptions.Cardiac Rehabilitation Patient Referral†1,2,3,4Regional or National PCI Registry Participation†2,3,41The guideline Class of Recommendation is 1, but Level of Evidence is only C.Annual Operator PCI Volume‡2,3b1,3a,4
Non-ST-segment elevation myocardial infarction (NSTEMI) is a major cause of cardiovascular morbidity and mortality in the United States. It represents the highest risk category of non-ST-segment ...elevation acute coronary syndromes (NSTEACS), for which timely diagnosis and appropriate therapy are paramount to improve outcomes. Evidence-based treatment, with combination of antiplatelet and anticoagulant therapy, and with serious consideration of early coronary angiography and revascularization along with anti-ischemic medical therapy, is the mainstay of management for NSTEMI. Aggressive risk-factor control after the acute event is imperative for secondary prevention of cardiovascular events. Applying in practice the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations results in improved outcomes.
The role of patent foramen ovale (PFO) in patients with cryptogenic stroke (stroke of unknown cause) remains controversial, although an association seems likely in younger patients with atrial septal ...aneurysms and PFO. The mechanism of cryptogenic stroke in these patients is presumed to be paradoxical embolism via right-to-left shunt across the PFO. The available options for treatment include medical therapy with antiplatelet or anticoagulant therapy or closure of the PFO surgically or with use of transcatheter PFO closure devices. We describe 2 cases of bilateral device thrombosis associated with use of a transcatheter PFO closure device (CardioSEAL). To our knowledge, only 1 other case of thrombosis associated with use of this device has been reported.
ABSTRACT—Vasopeptidase inhibitors are potent new antihypertensive agents. The dual inhibition of ACE and neutral endopeptidase may result in synergistic humoral effects with unique hemodynamic ...actions. We investigated the hemodynamic and neurohumoral effects of vasopeptidase inhibition in conscious dogs made hypertensive by bilateral renal wrapping and subsequently instrumented for long-term assessment of left ventricular pressure and volume (n=8). Intravenous vasopeptidase inhibition (omapatrilat, 30 μmol/kg over 10 minutes) reduced peak left ventricular pressure (171±6 versus 130±6 mm Hg immediately after infusion, P <0.01) through arterial vasodilation (arterial elastance, 9.8±0.8 to 5.8±1.6 mm Hg/mL, P <0.01) and preload reduction (left ventricular end-diastolic volume, 51.1±6.8 to 46.0±6.9 mL, P <0.01). At 60 minutes, preload decreased further (40.5±5.9 mL, P <0.01 versus baseline). Vasopeptidase inhibition increased plasma levels of adrenomedullin (41.2±9.6 versus 72.3±15 pg/mL, P <0.01), whereas levels of the natriuretic peptides and cGMP were unchanged. Similar hemodynamic and humoral effects were observed with long-term therapy. Neither an equimolar dose of an ACE inhibitor (fosinopril) nor exogenous adrenomedullin had as potent of a hypotensive effect, and neither reduced preload. In summary, the potent short-term and long-term hypotensive effects of vasopeptidase inhibition were prominently mediated by preload reduction, an effect not reproduced by ACE inhibition nor adrenomedullin augmentation and not associated with enhanced natriuretic peptide levels. Combined arterial vasodilation and preload reduction may confer additional potency as well as unique cardioprotective effects. Synergistic effects on humoral and probably endothelial vasodilatory factors appear to be important in mediating the unique hemodynamic profile of vasopeptidase inhibition in this form of experimental hypertension.
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