Alberto Hendler

LINCS: L-NAME (a NO synthase inhibitor) in the treatment of refractory cardiogenic shock a prospective randomized study

AIMS To evaluate the effect of L-NAME (a nitric oxide synthase inhibitor) in the treatment of refractory cardiogenic shock. METHODS AND RESULTS We enrolled 30 consecutive patients with refractory cardiogenic shock (systolic blood pressure that deteriorated progressively to <100 mmHg during an acute coronary syndrome despite maximal percutaneous coronary revascularization, intra aortic balloon pump, and IV dopamine, furosemide and fluids treatment for at least 1h, accompanied by signs of peripheral hypoperfusion). Patients were randomized to supportive care alone (n=15, control group) or to supportive care in addition to L-NAME (1mg/Kg bolus and 1mg/Kg/h continuous IV drip for 5h n=15). Death at one month was 27% in the L-NAME group vs. 67% in the control group (p=0.008). Unaugmented mean arterial blood pressure at 24 h from randomization was 86+/-20 mmHg in the L-NAME group vs. 66+/-13 mmHg in the control group (p=0.004). Urine output increased at 24h by 135+/-78 cc/h in the L-NAME group vs a decrease of 12+/-87 cc/h in the control group (p<0.001). Time on IABP and time on mechanical ventilation were significantly shorter in the L-NAME group. CONCLUSIONS The results of the present study further support our previous observation that NO synthase inhibitors are beneficial in the treatment of patients with refractory cardiogenic shock.

Minimal heparinization in coronary angioplasty—how much heparin is really warranted?

The purpose of the study was to assess the results of percutaneous transluminal coronary angioplasty (PTCA), performed with a single intravenous bolus of 2,500 U of heparin, in a nonemergency PTCA cohort. Three hundred of 341 consecutive patients (87.9%) undergoing PTCA were prospectively enrolled in the study. They received heparin, 2,500-U intravenous bolus, before PTCA, with intention of no additional heparin administration. Patient and lesion characteristics as well as PTCA results were evaluated independently by 2 physicians. Patients were followed up by structured telephone questionnaires at 1 and 6 months after PTCA. Mean activated clotting time obtained 5 minutes after heparin administration was 185+/-19 seconds (range 157 to 238). There were 3 (1%) in-hospital major adverse cardiovascular events: 2 deaths (0.66%), 1 (0.33%) Q-wave myocardial infarction. Emergency coronary surgery and stroke were not reported. Six patients (2%) experienced abrupt coronary occlusion within 14 days after PTCA, warranting repeat target vessel revascularization. Angiographic and clinical success were achieved in 96% and 93.3%, respectively. No bleeding or vascular complications were recorded. Six-month follow-up (184 patients) revealed 3 cardiac deaths (1 arrhythmic, 2 after cardiac surgery), 1 Q-wave myocardial infarction, and 9.7% repeat target vessel revascularization. This study suggests that very low doses of heparin and reduced activated clotting time target values are safe in non-emergency PTCA, and can reduce bleeding complications, hospital stay, and costs. Larger, randomized, double-blind heparin dose optimization studies need to confirm this notion.

A Right Atrial Mass in the Presence of a Permanent Pacemaker Electrode in a Patient with Polycythemia Vera

A case of a huge right atrial mass that developed 2 years after a permanent pacemaker implantation is described. The patient had a history of polycythemia vera, which is known to present a high tendency towards the development of thrombosis. In light of this fact, we suggest that in similar cases a full echocardiography follow‐up should be performed, and long‐term anticoagulant therapy should be considered in selected cases.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting.

BACKGROUND Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting. METHODS From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities. RESULTS The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015). CONCLUSIONS Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

An Unusual Presentation of a Large Left Ventricular Pseudoaneurysm

Left ventricle pseudoaneurysm is an infrequent complication of myocardial infarction, and is most commonly localized in the inferoposterior left ventricular segments. We describe a patient post anterior myocardial infarction, who presented with pulmonary edema and a large pseudoaneurysm of the anterolateral wall with involvement of the anterolateral papillary muscle, resulting in severe mitral regurgitation. The patient underwent successful operation and is currently well.

Cardiac Rupture: New Features of the Old Disease

Objectives: Myocardial rupture is a rare but a fatal complication of acute myocardial infarction. During recent years, treatment strategies of acute myocardial infarction have changed. Primary percutaneous coronary interventions have replaced fibrinolytic therapy, thus reducing one of the major risk factors for myocardial rupture. In this work, we describe a group of patients who suffered myocardial rupture, none of whom were treated with thrombolytic therapy. Methods: The digital database of our hospital was searched for all patients who experienced myocardial rupture between 2008 and 2015. The demographic, clinical, angiographic and echocardiographic data of these patients were analyzed. Results: Out of 2,380 patients admitted with acute myocardial infarction, 12 (0.5%) developed myocardial rupture. The mean age was 78 years, and there were 7 males and 5 females. Ten patients already had pericardial effusion on admission. Seven patients underwent coronary angiography, whilst primary percutaneous intervention was performed in 4 patients. Six patients entered the operating room and all survived the procedure. All patients who were treated conservatively died due to rupture. Factors related to the treatment strategy were advanced age (≥90 years) and cognitive impairment. Conclusions: The risk of myocardial rupture may be diminished by primary coronary intervention during myocardial infarction, but mortality remains high. An early, comprehensive echocardiographic examination and rapid surgery may contribute to improved survival.

A novel concept in endovascular stenting for the treatment of old severely degenerated saphenous vein graft in the urgent setting.

We report a critically ill‐patient admitted for NSTEMI with acute pulmonary congestion, showing at urgent cardiac catheterization a severely diseased saphenous vein graft as the culprit vessel, with huge atherothrombotic burden. The graft was successfully revascularized by the implantation of 4 M‐Guard stent (for proximal to distal) creating a full metal jacket. The M‐Guard technology consists on a stainless steel platform wrapped by a micron‐level polymer net, that seamlessly expands when the stent is deployed, providing protection from embolic showers.

Adjunctive pharmacotherapy for coronary interventions—time to read the writing on the wall

With the new era of coronary stenting supported by triple anti‐platelet therapy, in‐hospital life threatening ischemic complications are rare, and minimally affected by the intensity and duration of the anti‐coagulation protocol. Bleeding complications, however, became the most commonly observed adversity of percutaneous coronary intervention. Hemorrhagic complications are clearly related to the intensity and duration of anti‐coagulation and platelet inhibition protocols, and result in excessive mortality, morbidity, and medical costs. Demographic and clinical predictors of bleeding complications are reviewed. Accumulating data on the safety of PCI with low‐dose unfractionated heparin is pointed out. In view of the contemporary data, the authors question the recently published European and American guideline, which suggest uniform dosing and therapeutic targets for both anticoagulants and glycoprotein IIb/IIIa blockers. Instead, we suggest that these agents will be used judiciously and cautiously tailored, bearing in mind their benefits against the potential to harm. After over three decades of PCI, it is time to engage in dose and duration optimizing studies for these agents.

A 45-year-old woman with chest pain after coronary stenting.

A 45-year-old woman with history of diabetes mellitus and smoking underwent coronary angiography due to unstable angina. During the intubation of the left main coronary artery, pressure drop was observed and ostial left main stenosis was found ( Panel A ). The patient complained of chest pain and immediate stenting of the left main coronary artery was performed …

Heart Failure and a Right Ventricular Mass: Pitfalls on the Way to the Diagnosis

(Echocardiography 2011;28:482‐486)