Barbara Naegeli

Proinflammatory cytokines in acute myocardial infarction with and without cardiogenic shock.

BackgroundInflammatory response is an important feature of acute coronary syndromes and myocardial infarction (MI). The prognostic value of proinflammatory cytokines in patients with acute MI complicated by cardiogenic shock is unknown.Methods and resultsIn 41 patients admitted with acute MI (age 60 ± 11 years, six females, 19 Killip class IV) serial plasma concentration of tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6) and interleukin 1 receptor antagonist (IL-1Ra) were measured. Seven patients with cardiogenic shock (CS) developed a systemic inflammatory response syndrome (SIRS). Patients with CS—particularly those who developed SIRS—showed significantly higher cytokine levels than patients with uncomplicated MI. In patients with CS and SIRS peak levels of IL-1Ra were 223,973 pg/ml, IL-6 252.8 pg/ml and TNF-α 7.0 pg/ml. In CS without SIRS IL-1Ra levels were 19,988 pg/ml, IL-6 109.3 pg/ml and TNF-α 3.8 pg/ml. In uncomplicated MI peak IL-1Ra levels were 1,088 pg/ml, IL-6 34.1 pg/ml and TNF-α 2.6 pg/ml.ConclusionsThe inflammation-associated cytokines TNF-α, IL-6 and IL-1Ra are significantly elevated in patients with MI complicated by CS when compared to patients with uncomplicated MI. Among shock-patients IL-1Ra levels are promising diagnostic markers for early identification of patients developing SIRS, heralding a poor outcome.

Epicardial, Biatrial Synchronous Pacing for Prevention of Atrial Fibrillation after Cardiac Surgery

About 30% of patients develop AF after open heart surgery. Biatrial synchronous pacing (BSP) has been shown to promote sinus rhythm in patients with paroxysmal AF refractory to drug therapy. We conducted a prospective, randomized study to test the effect of BSP via epicardial electrodes on the incidence of AF after heart surgery, as compared to conventional therapy. To apply BSP, we attached two epicardial electrodes to the right and one to the left atrium. Immediately following surgery, BSP was initiated in the AAI‐Mode at a rate of 10 beats/min above the underlying rhythm (maximum 110 beats/min) and continued for 3 days, during which the rhythm was continually monitored. After 21 (age 63 ± 9 years) of the planned 200 patients, the study was prematurely aborted because of the proarrhythmic effect of BSP; 6 of the 12 patients treated with BSP developed sensing failure (P amplitude < 1 mV), which provoked AF in 5 of these 6 patients. BSP was discontinued due to diaphragmal stimulation in two patients and due to ventricular stimulation by a dislocated left atrial electrode in one patient. Two patients in the control group (n = 9) developed AF. Using the available standard technology, BSP via epicardial electrodes is not suitable to suppress AF after heart surgery, primarily due to postoperative deterioration of atrial sensing and its profibrillatory effect. In patients requiring atrial pacing after heart surgery, sensing thresholds must be closely monitored to prevent induction of AF.

VDD(R) pacing: short- and long-term stability of atrial sensing with a single lead system.

Background: Recent studies have shown that the atrial signal can reliably be sensed for VDD(R) pacing via atrial floating electrodes incorporated in a single‐pass lead. However, there remains concern about the long‐term stability of atrial sensing and proper VDD function under real‐life conditions. This study investigated the long‐term reliability of atrial sensing and atrioventricular synchronous pacing using a new single lead VDD(R) pacing system. Methods and Results: In 20 consecutive patients (ages 71 ± 14 years) with normal sinus node function and high‐degree heart block, a single lead VDD(R) pacemaker (Unity(tm), Intermedics) was implanted, Atrial sensing was studied at implantation, at discharge, and at 1, 3, 6, 12, and 18 months of follow‐up. At implant, the measured P wave amplitude was 2.3 ± 1.2 mV. By telemetry, the atrial sensing threshold was 0.79 ± 0.41 mV at discharge, 0.75 ± 0.43 mV at 1 month, 0.73 ± 0.43 mV at 3 months, 0.76 ± 0.41 mV at 6 months, 0.79 ± 0.41 mV at 12 months, and 0.77 ± 0.35 mV at 18 months of follow‐up (P = NS). Appropriate VDD pacing was assessed by the percentage of correct atrial synchronization (PAS = atrial triggered ventricular paced complexes ± total number of ventricular paced complexes) during repeated Holters. PAS was 99.99%± 0.01 % at 1 month, 99.99%± 0.02% at 3 months, and 99.98%± 0.05% at 12 months of follow‐up (P = NS). No atrial oversensing with inappropriate ventricular pacing was observed, neither during isometric arm exercise testing nor spontaneously during Holier monitoring. Conclusion: The long‐term stability of atrial sensing with almost 100% correct atrial synchronous tracking and the lack of inappropriate pacing due to atrial oversensing make the new Unity VDD(R) system a highly reliable single lead pacing system. In view of the lower costs and the ease of single lead implantation, this system may offer an interesting alternative to DDD pacemakers in patients with normal sinus node function.

Long-term outcome of acute myocarditis is independent of cardiac enzyme release

BACKGROUND There are few data concerning prognostic markers of acute myocarditis. The purpose of this study was to assess the prognostic value of initial measurements of creatine kinase (CK), cardiac troponin I (cTnI) and myoglobin as regards late recovery of the left ventricular ejection fraction on follow-up. METHODS A total of 22 patients (53+/-15 years old, 11 female) with acute myocarditis were followed up in a prospective observational study. Of these, 11 (50%) showed a history of acute infection prior to hospitalisation and seven (32%) had pericardial effusion. The median ejection fraction during the acute phase was 47+/-17%; after a mean follow-up of 119+/-163 days it improved to 60+/-9% (P<0.001). Considering maximal CK-rise values of 641+/-961 U/l (P=0.38), cTnI-rise values of 3.7+/-8.6 microg/l (P=0.16) and myoglobin values of 7.4+/-12 nmol/l (P=0.69), there was no correlation between initial cardiac enzyme levels and the initial and late left ventricular ejection fraction. CONCLUSION After acute myocarditis, there is late recovery of left ventricular ejection fraction, which is independent of the initial myocardial damage measured by cardiac enzyme release.

A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of postprocedural chest pain and minor myocardial necrosis after elective coronary stenting

BACKGROUND Anginal chest pain without creatine kinase (CK) elevation is frequently observed in the first hours after coronary stenting. Possible causes of ischemic episodes are microembolism, side branch occlusion, coronary vasospasm, and disturbances of microvascular circulation. In a prospective, double-blind, randomized trial, we tested the effect of intravenous nitroglycerin on the incidence of angina and minor myocardial necrosis (MMN), as detected by cardiac troponin I increase, after elective coronary stenting. METHODS AND RESULTS One hundred patients were randomly assigned to intravenous nitroglycerin (group A: n = 50, goal dose 100 microgram/min) or placebo (group B: n = 50, NaCl 0.9%) during 12 hours after stenting. Patients with acute myocardial infarction, known intolerance to nitrates, and hemodynamic instability during angioplasty were excluded. The 2 groups were comparable in respect to baseline and interventional variables, except for age (group A: 60 +/- 9 years, group B: 56 +/- 10 years; P =.04). The incidence of chest pain was not influenced by nitroglycerin (group A: 18%, group B: 22%; P = not significant). However, the occurrence of MMN was significantly reduced by nitroglycerin (group A: 5%, group B: 19%, P =.036). A rise in CK with significant CK-MB fraction was observed in only 2 patients in group B (both less than twice upper limit). Only 4 of the 10 patients with MMN also had chest pain. CONCLUSIONS Routine use of intravenous nitroglycerin after coronary stenting significantly reduced the occurrence of minor myocardial necrosis. However, the incidence of postprocedural chest pain remained unchanged.

Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome

Background: To improve the outcome in patients with acute coronary syndrome (ACS), public campaigns have been launched aimed at shortening presentation delays and allowing more efficient treatment. Their impact is uncertain. Methods: Pre-hospital delays and outcome in patients with ACS included in the Swiss National AMIS Plus registry were assessed prospectively before and after a nationwide multimedia campaign (‘HELP’) by the Swiss Heart Foundation in 2007. The campaign aimed at better awareness of symptoms, increasing knowledge in laymen of resuscitation and more rapid access to medical services. The primary study endpoint was the time between onset of symptoms and hospital admission. Secondary endpoints were successful out-of-hospital resuscitation, symptoms upon admission, and outcome. Results: Between January 2005 and December 2008, 8906 ACS patients (61% ST-segment elevation myocardial infarction (STEMI), 39% non-ST-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP), mean age 65 ± 13 years, 75% males) admitted within 24 hours after onset of symptoms were enrolled. The median pre-hospital delay was reduced from 197 minutes during the pre-intervention period to 180 minutes during the post-intervention period (reduction 10% (95% confidence interval (CI) 6–14%); P < 0.001), in STEMI (reduction 10% (95% CI 5–14%); P < 0.001) and NSTEMI patients (reduction 11% (95% CI 4–17%); P = 0.001), due to pronounced effects in males (reduction 12% (95% CI 7–16%); P < 0.001) and in patients ≤75 years (reduction 12% (95% CI 8–16%); P < 0.001). Out-of-hospital resuscitation increased (odds ratio (OR) 1.26 (95% CI 1.06–1.54); P = 0.02). Overall outcome remained unchanged, however, the rate of re-infarction showed a decrease (OR 0.58 (95% CI 0.36–0.91); P = 0.021). Conclusions: After a nationwide educational campaign, shorter pre-hospital delays were observed, and more patients were able to be treated promptly. These results may be useful in planning future health strategies to improve management and outcome of patients with ACS, especially in female and elderly patients.

An Uncommon Cause of Recurrent Strokes Tropheryma whippelii Endocarditis

BACKGROUND Cardiac involvement in Whipples disease is not an uncommon phenomenon in autopsies, but its clinical occurrence is often overshadowed by gastrointestinal symptoms. We report a very atypical manifestation of this disorder. SUMMARY OF REPORT An extraordinary presentation of an extremely long-lasting, culture-negative endocarditis caused by Tropheryma whippelii is described, the clinical consequence of which has become apparent in recurrent strokes. CONCLUSIONS Cardiac involvement of Whipples disease should always be considered in culture and serologically negative endocarditis. The polymerase chain reaction technique may be a useful tool to confirm a presumed diagnosis of T whippelii endocarditis and consequently to apply an effective treatment regimen.

Long-term results after acute percutaneous transluminal coronary angioplasty in acute myocardial infarction and cardiogenic shock

The aim of this study was to determine the long-term outcome in unselected, consecutive patients after acute percutaneous transluminal angioplasty (PTCA) for acute myocardial infarction (AMI) complicated by cardiogenic shock. This involved a follow-up study from a prospectively conducted patient registry in a tertiary referral center. A total of 59 patients (10 female/49 male; median age 62 years (32-91)) with percutaneous transluminal cardiac interventions in primary cardiogenic shock were identified between January 1995 and January 2000. Twenty-two patients (37%) had been resuscitated successfully before intervention. The in-hospital mortality of shock patients was 36% (n=21, median age 68 (47-84)). The median follow-up of survivors was 18.1 (7-57.3) months, during which three further patients died (8%; two because of sudden cardiac deaths, one because of acute reinfarction). Achievement of thrombolysis in myocardial infarction (TIMI) flow III after acute PTCA (84% in survivors vs. 38% in non-survivors; P<0.001) and the absence of the left main coronary artery (3% survivors vs. 29% non-survivors; P=0.003) as culprit lesion in patients with cardiogenic shock was strongly associated with an improved survival rate. A second cardiac intervention was performed in seven patients (18%). Overall functional capacity of shock survivors was good. At final follow-up, 80% of the survivors were completely asymptomatic. One patient had angina pectoris NYHA II, five patients dyspnoea NYHA class II. Exercise stress-test was performed in 24 of the 38 surviving patients, median exercise capacity was 100% (range 55-113%) of the age adjusted predicted value. In unselected patients with cardiogenic shock due to AMI, treatment with acute PTCA resulted in an in-hospital mortality of 36%, low late mortality and good functional capacity in long-term survivors. TIMI flow grade III after acute PTCA in patients with acute myocardial infarction complicated by cardiogenic shock was strongly associated with an improved survival rate whereas the left main coronary artery as culprit lesion was associated with worse outcome.

Prevention of atrial fibrillation after cardiac valvular surgery by epicardial, biatrial synchronous pacing

OBJECTIVE Postoperative atrial fibrillation (AF) after cardiac surgery is a frequent complication after valvular surgery (30-60%). The purpose of this prospective, randomized study was to determine if biatrial synchronous pacing reduces postoperative AF after cardiac valvular surgery as compared to conventional therapy. METHODS Eighty patients subjected to valvular surgery (52 men, age 66 +/- 10 years) were randomized to one of two groups: one group was treated with biatrial, synchronous pacing (BAP) for 72 h postoperatively (n=40) the other group received no atrial pacing (controls; n=40). All patients had one pair of epicardial wires attached to the right atrium. An additional electrode was placed to the left atrium in the BAP group. These patients were continuously paced at a rate of 10 beats per minute higher than the intrinsic rate starting immediately after surgery. All patients were monitored with full disclosure telemetry or Holter monitors to identify onset of AF. RESULTS Eighteen of the 40 patients in the control group (45%) developed AF within the first 3 days postoperatively as compared to eight patients (20%) in the BAP group (P=0.02). No complications occurred associated with the placement, maintenance and removal of the atrial pacing electrodes. CONCLUSIONS Temporary, biatrial synchronous pacing during the first 3 postoperative days is safe and has a significant rhythm-stabilizing effect in patients undergoing valvular cardiac surgery.

Dual Chamber Pacing with a Single-Lead DDD Pacing System

The successful application of single‐lead VDD pacing during the last few years has generated the idea of single‐lead DDD pacing. Preliminary data from several single‐lead VDD studies attempting to pace the atrium by a floating atrial dipole are unsatisfactory, causing an unacceptably high current drain of the device. We studied the feasibility as well as the short‐ and long‐term stability of atrioventricular sequential pacing, using a new single‐pass, tined DDD lead. In eight consecutive patients (age 73 ± 16 years) with symptomatic higher degree A V block and intact sinus node function, this new single‐pass DDD lead was implanted in combination with a DDDR pacemaker. Correct VDD and DDD function was studied at implantation; at discharge; and at 1,3, and 6 months of follow‐up. At implant, the atrial stimulation threshold was 0.6 ± 0.1 V/0.5 ms. During follow‐up, the atrial pacing thresholds in different everyday positions averaged 2.1 ± 0.5 V at discharge, 2.9 ± 0.5 V at 1 month, 3.8 ± 0.4 V at 3 months, and 3.4 ± 0.4 V at 6 months (pulse width always 0.5 ms). The measured P wave amplitude at implantation was 4.5 ± 2.2 mV; during follow‐up the telemetered atrial sensitivity thresholds averaged 2.1 ± 0.3 mV. Phrenic nerve stimulation at high output pacing (5.0 V/0.5 ms) was observed in three (38%) patients at discharge and in one (13%) patient during follow‐up; an intermittent unmeasurable atrial lead impedance at 3 and 6 months follow‐up was documented in one (13%) patient. This study confirms the possibility of short‐and long‐term DDD pacing using a single‐pass DDD lead. Since atrial stimulation thresholds are still relatively high compared to conventional dual‐lead DDD pacing, further improvements of the atrial electrodes are desirable, enabling lower pacing thresholds and optimizing energy requirements as well as minimizing the potential disadvantage of phrenic nerve stimulation.