Aryeh Shalev

Incidence, Risk Factors, Management and Outcomes of Coronary Artery Perforation During Percutaneous Coronary Intervention

Coronary artery perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention. There are limited controlled contemporary data regarding its predictors, incidence, and outcomes. The aim of this study was to define the incidence, associated factors, and outcomes of CP in the current era of coronary intervention. All patients who had CP during percutaneous coronary intervention at a large tertiary center from January 2001 to December 2008 were identified. Demographic, clinical, and procedural data and outcome variables were obtained. Patients with CP were compared with a randomly assigned control group. Fifty-seven patients with CP were identified among 9,568 interventions performed during the study period (0.59%); these patients were compared with 171 who underwent percutaneous coronary intervention without CP. Vessels were perforated by wires (52.6%), balloons (26.3%), and stents (21.1%). Perforations were classified using the Ellis classification. CP was associated with mortality and tamponade rates of 7% and 16%, respectively, but all these serious complications occurred with grade III perforations. Most grade I and II perforations were managed conservatively. Multivariate analysis identified the treatment of chronic total occlusion as the strongest independent predictor of CP; other independent variables included calcium in the coronary artery that was the site of intervention and non-ST elevation myocardial infarction.

Cell free DNA detected by a novel method in acute ST-elevation myocardial infarction patients

Abstract Background: High levels of circulating cell free DNA (CFD) have been associated with poor prognosis in various diseases. Data pertaining to CFD in acute myocardial infarction (MI) are scarce. The available data have been obtained by either electrophoresis or polymerase chain reaction. We evaluated a novel method for the detection of CFD in patients with ST elevation myocardial infarction (STEMI) and examined its correlation with established markers of necrosis and ventricular function. Methods: Serum concentrations of CFD, troponin-T and creatine kinase (CK) were measured simultaneously in 16 randomly selected acute STEMI patients upon admission and at three more time points. 47 healthy subjects served as a control group. CFD was quantified by a novel rapid fluorometric assay. Ejection fraction (EF) was assessed by echocardiography. Results: Peak CFD levels were significantly higher in patients compared with controls (P = 0.001) and correlated with peak levels of CK and troponin-T (R = 0.79, P <0.001); R = 0.65, P = 0.006, respectively). Peak CFD levels tended to be associated with lower EF (P = 0.075). Conclusion: With this method, CFD levels correlated with the levels of established markers of myocardial necrosis but not with EF. The kinetic pattern of CFD release after STEMI and its prognostic value require further investigation.

Incidence, predictors and outcome of upper gastrointestinal bleeding in patients with acute coronary syndromes.

BACKGROUND The broad utilization of revascularization and antithrombotic therapy in patients with acute coronary syndrome (ACS) is associated with a substantial risk of bleeding primarily related to arterial punctures, which can lead to worse outcome. AIM To define the characteristics and outcome of patients who develop upper gastrointestinal bleeding (UGIB) in the setting of ACS. METHODS We identified all patients admitted to the coronary care unit between 10/96 and 11/07 with ACS who developed UGIB. For each case 3 control cases were matched. Multiple baseline characteristics, as well as antithrombotic agents, revascularization strategy and endoscopy reports were assessed. Mortality at 30-day was the primary endpoint of the analysis. RESULTS Of 7240 ACS patients, 64 (0.9%) developed UGIB. There were no significant differences between groups in the prevalence of diabetes and other risk factors, revascularization strategy, or the use of proton pump inhibitors. Patients with UGIB suffered more from renal impairment and left ventricular dysfunction and were more frequently treated with thienopyridines (89% vs. 68%, p=0.002) and glycoprotein IIb/IIIa inhibitors (39% vs. 24%, p=0.03). The combination of unfractionated heparin (UFH) with glycoprotein IIb/IIIa inhibitors was strongly associated with UGIB (OR: 2.87, 95% CI 1.66-4.97). Patients who developed UGIB had a substantially higher 30-day mortality rate (33% vs. 5%, p<0.001). CONCLUSIONS UGIB in patients with ACS is associated with a markedly increased mortality. Previous peptic disease and the use of combined anti-platelet therapy, especially in conjunction with heparin, are strong risk factors for this serious complication.

New insights into the atrial electrophysiology of rodents using a novel modality: the miniature-bipolar hook electrode

Studies of atrial electrophysiology (EP) in rodents are challenging, and available data are sparse. Herein, we utilized a novel type of bipolar electrode to evaluate the atrial EP of rodents through small lateral thoracotomy. In anesthetized rats and mice, we attached two bipolar electrodes to the right atrium and a third to the right ventricle. This standard setup enabled high-resolution EP studies. Moreover, a permanent implantation procedure enabled EP studies in conscious freely moving rats. Atrial EP was evaluated in anesthetized rats, anesthetized mice (ICR and C57BL6 strains), and conscious rats. Signal resolution enabled atrial effective refractory period (AERP) measurements and first time evaluation of the failed 1:1 atrial capture, which was unexpectedly longer than the AERP recorded at near normal cycle length by 27.2+/-2.3% in rats (P<0.0001; n=35), 31.7+/-8.3% in ICR mice (P=0.0001; n=13), and 57.7+/-13.7% in C57BL6 mice (P=0.015; n=4). While AERP rate adaptation was noted when 10 S1s at near normal basic cycle lengths were followed by S2 at varying basic cycle length and S3 for AERP evaluation, such rate adaptation was absent using conventional S1S2 protocols. Atrial tachypacing in rats shortened the AERP values on a timescale of hours, but a reverse remodeling phase was noted thereafter. Comparison of left vs. right atrial pacing in rats was also feasible with the current technique, resulting in similar AERP values recorded in the low right atrium. In conclusion, our findings indicate that in vivo rate adaptation of the rodent atria is different than expected based on previous ex vivo recordings. In addition, atrial electrical remodeling of rats shows unique remodeling-reverse remodeling characteristics that are described here for the first time. Further understanding of these properties should help to determine the clinical relevance as well as limitations of atrial arrhythmia models in rodents.

Doxazosin to treat hypertension: it's time to take it personally--a retrospective analysis of 19, 495 patients.

Objective: The aim of the current study was to evaluate the effect of &agr; blockers on the cardiac outcomes of hypertensive patients who underwent myocardial perfusion imaging (MPI). Methods: A retrospective analysis of the nuclear cardiology laboratory database was performed. The study group included only hypertensive patients (n = 19 495). The cohort was divided into three groups – a reference group of no &agr;-blocker therapy (n = 17 053), &agr; blockers for benign prostatic hypertrophy (BPH) (n = 1164), and doxazosin for hypertension (HTN) (n = 1258). We used Cox proportional regression models to examine the patient cardiac outcomes (composite of cardiovascular mortality and myocardial infarction) adjusted for the myocardial perfusion study results. The mean age was 65 ± 11.1 years, 55% were men, and the average follow-up was 79.2 ± 37.3 months. Results: In univariate analysis, the doxazosin for HTN group had the highest rate of adverse cardiac events in comparison to the BPH and reference groups (14.1 vs. 11.3% and 8.9%, respectively, P < 0.001). After stratifying for the degree of reversibility of perfusion defect, only individuals with a moderate-to-severe perfusion defect in the doxazosin for HTN group had a significant increase in adverse cardiac events [hazard ratio 1.50 95% confidence interval (1.14–1.98)]. Conclusion: Our data show that doxazosin treatment for HTN is associated with adverse cardiac outcome only among patients with moderate-to-severe ischemia on myocardial perfusion imaging. Doxazosin and other &agr; blockers appear to be safe in the vast majority of patients with a lesser degree of ischemia.

INO-8875, a Highly Selective A1 Adenosine Receptor Agonist: Evaluation of Chronotropic, Dromotropic, and Hemodynamic Effects in Rats

Selective pharmacological activation of the adenosine 1 receptor (A1R) is a promising new approach to achieve a potent block of atrioventricular (A-V)–nodal conduction without significant cardiovascular side effects. The purpose of the present study was to evaluate the cardiovascular profile of INO-8875, a highly selective A1R agonist, and to compare its properties with N-[3(R)-tetrahydrofuranyl]-6-aminopurine riboside (CVT-510), which has already been shown to induce negative dromotropic effects with minimal cardiovascular side effects in animals and in clinical studies. Dose-response experiments in the isolated hearts of rats were used to evaluate the functional selectivity of INO-8875 for the slowing of A-V–nodal conduction. Ventilated adult rats were used to study the effects of INO-8875, in vivo, on arterial blood pressure as well as on supraventricular electrophysiology. Ex vivo, INO-8875 (100 nM to 3 μM) progressively prolonged A-V–nodal conduction without reducing left ventricular function or coronary resistance. In vivo, INO-8875 up to a dose of 50 μg/kg did not reduce the carotid arterial blood pressure (n = 4). INO-8875 (1–50 μg/kg) and CVT-510 (20 and 50 μg/kg) both induced a dose-dependent decrease in heart rate and atrial refractoriness, as well as slowing of A-V–nodal conduction. However, compared with CVT-510, the activity of INO-8875 was more pronounced in A-V–nodal function. INO-8875 exhibited a greater duration of action, lasting up to 2.5 hours post dosing, whereas the effects of CVT-510 dissipated over 1 hour. INO-8875 demonstrates functional properties of a highly selective A1R agonist. INO-8875 exhibits an increased dromotropic effect and greater duration of action compared with CVT-510.

Commotio Cordis in a Professional Soccer Player: Value of MRI in Unraveling Myocardial Damage

A 35-year-old male premier league soccer player was admitted to the intensive coronary care unit after aborted cardiac sudden death. A routine echocardiogram performed 2 years earlier was entirely normal. The player was struck along the left anterior chest wall by a direct blow from a soccer ball during a practice game. He reported a prodrome of dizziness for several minutes before collapsing on the field. An emergency medical team documented monomorphic ventricular tachycardia, which rapidly deteriorated to ventricular fibrillation. Four electric shocks were delivered with the restoration of sinus rhythm and immediate full neurological recovery. Initial workup revealed elevated high-sensitivity cardiac troponin T of 283 ng/L (normal range, 0–14 ng/L) and creatine kinase levels of 12 480 U/L (normal range, 20–200 U/L). The 12-lead ECG showed biphasic T waves in the precordial leads, with a normal QTc interval. Transthoracic echocardiography revealed mild biventricular dysfunction (Movie I in the Data Supplement). Coronary angiography showed normal coronary arteries (Movie II in the Data Supplement). Cardiac magnetic resonance (CMR) study with a 3T scanner (Ingenia, Philips Medical Systems, Best, The Netherlands) was performed on day 4 after …