Chalak Berzingi

Differential Diagnosis of Acute Pericarditis From Normal Variant Early Repolarization and Left Ventricular Hypertrophy With Early Repolarization: An Electrocardiographic Study

Background:Differentiation of ST-segment elevation on electrocardiogram (ECG) from acute pericarditis (AP), normal variant early repolarization (ER) and early repolarization of left ventricular hypertrophy (ERLVH) can be problematic. Hence, the authors evaluated the accuracy of the ST/T ratio in ECG to more optimally differentiate between AP, ST-segment elevation, ER and ERLVH. Methods:Between September 2006 and July 2010, 80 patients were enrolled in this study consisting of 25 individuals with AP, 27 with ER and 28 with ERLVH. Each ECG was analyzed in a systematic manner including the measurement of PR interval, QRS duration, QT-segment duration, PR-segment deviation, ST-segment deviation and the height of T wave. The ratio of the height of ST segment to the height of T wave was measured in leads I, II, III, aVF and V2 through V6. Results:The mean ages of the patients with AP, ER and ERLVH were 32 ± 16.5, 36 ± 15.4 and 53 ± 16 years, respectively. The ratio of the amplitude of ST segment to the amplitude of the T wave in leads I, V4, V5 and V6 proved to be a significant discriminator at a value of ≥0.25 (P < 0.05 for all). Conclusions:Leads I, V4, V5 and V6 can all be used to differentiate AP from ER and ERLVH. When ST elevation is present in lead I, the ST/T ratio has the best predictive value (0.82) to more accurately discriminate between AP, ER and ERLVH.

Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation

Background Tricuspid regurgitation (TR), if untreated, is associated with an adverse impact on long‐term outcomes. In recent years, there has been an increasing enthusiasm about surgical and transcatheter treatment of patients with severe TR. We aim to evaluate the contemporary trends in the use and outcomes of tricuspid valve (TV) surgery for TR using the National Inpatient Sample. Methods and Results Between January 1, 2003 and December 31, 2014, an estimated 45 477 patients underwent TV surgery for TR in the United States, of whom 15% had isolated TV surgery and 85% had TV surgery concomitant with other cardiac surgery. There was a temporal upward trend to treat sicker patients during the study period. Patients who underwent isolated TV repair or replacement had a distinctly different clinical risk profile than those patients who underwent TV surgery simultaneous with other surgery. Isolated TV replacement was associated with high in‐hospital mortality (10.9%) and high rates of permanent pacemaker implantation (34.1%) and acute kidney injury requiring dialysis (5.5%). Similarly, isolated TV repair was also associated with high in‐hospital mortality (8.1%) and significant rates of permanent pacemaker implantation (10.9%) and new dialysis (4.4%). Isolated TV repair and TV replacement were both associated with protracted hospitalizations and substantial cost. Conclusions In contemporary practice, surgical treatment of TR remains underused and is associated with high operative morbidity and mortality, prolonged hospitalizations, and considerable cost.

Percutaneous axillary access for large-bore arteriotomy: A step-by-step guide

The last decade has witnessed a tremendous growth in the type and complexity of transcatheter cardiovascular interventions that require large‐bore access. While the common femoral artery has become the main route for these interventions, sizable cohorts of patients are unsuitable for transfemoral access due to vascular disease or small vessel caliber. Percutaneous axillary access has emerged as a feasible alternative in these patients. We provide a step‐by‐step guide for transaxillary large‐bore access and closure for patients requiring transcatheter interventions.

Contrast use in relation to the arterial access site for percutaneous coronary intervention: A comprehensive meta-analysis of randomized trials

AIM To compare the amount of contrast used during percutaneous coronary intervention (PCI) via trans-radial access (TRA) vs trans-femoral access (TFA). METHODS Scientific databases and websites were searched for:randomizedcontrolledtrials (RCTs). Data were extracted by two independent reviewers and was summarized as the weighted mean difference (WMD) of contrast used with a 95%CI using a random-effects model. RESULTS The meta-analysis included 13 RCTs with a total of 3165 patients. There was no difference between the two strategies in the amount of contrast used (WMD = - 0.65 mL, 95%CI: -10.94-9.46 mL; P = 0.901). CONCLUSION This meta-analysis shows that in patients undergoing PCI, the amount of contrast volume used was not different between TRA and TFA.

N-acetylcysteine reverses cardiac myocyte dysfunction in a rodent model of behavioral stress

Compelling clinical reports reveal that behavioral stress alone is sufficient to cause reversible myocardial dysfunction in selected individuals. We developed a rodent stress cardiomyopathy model by a combination of prenatal and postnatal behavioral stresses (Stress). We previously reported a decrease in percent fractional shortening by echo, both systolic and diastolic dysfunction by catheter-based hemodynamics, as well as attenuated hemodynamic and inotropic responses to the β-adrenergic agonist, isoproterenol (ISO) in Stress rats compared with matched controls (Kan H, Birkle D, Jain AC, Failinger C, Xie S, Finkel MS. J Appl Physiol 98: 77-82, 2005). We now report enhanced catecholamine responses to behavioral stress, as evidenced by increased circulating plasma levels of norepinephrine (P < 0.01) and epinephrine (P < 0.01) in Stress rats vs. controls. Cardiac myocytes isolated from Stress rats also reveal evidence of oxidative stress, as indicated by decreased ATP, increased GSSG, and decreased GSH-to-GSSG ratio in the presence of increased GSH peroxidase and catalase activities (P < 0.01, for each). We also report blunted inotropic and intracellular Ca(2+) concentration responses to extracellular Ca(2+) (P < 0.05), as well as altered inotropic responses to the intracellular calcium regulator, caffeine (20 mM; P < 0.01). Treatment of cardiac myocytes with N-acetylcysteine (NAC) (10(-3) M) normalized calcium handling in response to ISO and extracellular Ca(2+) concentration and inotropic response to caffeine (P < 0.01, for each). NAC also attenuated the blunted inotropic response to ISO and Ca(2+) (P < 0.01, for each). Surprisingly, NAC did not reverse the changes in GSH, GSSG, or GSH-to-GSSG ratio. These data support a GSH-independent salutary effect of NAC on intracellular calcium signaling in this rodent model of stress-induced cardiomyopathy.

Contemporary outcomes of isolated bioprothestic mitral valve replacement for mitral regurgitation

Background Early experience with transcatheter mitral valve replacement (TMVR) highlighted several investigational challenges related to this novel therapy. Conclusive randomised clinical trials in the field may, therefore, be years ahead. In the interim, contemporary outcomes of isolated surgical bioprosthetic mitral valve replacement (MVR) can be used as a benchmark for the emerging TMVR therapies. Methods We used the nationwide inpatient sample to examine recent trends and outcomes of surgical bioprosthetic MVR for mitral regurgitation (isolated and combined). Results 21 007 patients who had bioprosthetic MVR between 2003 and 2014 were included. Of those, 30% had isolated MVR and 70% had concomitant cardiac surgical procedure(s). In patients who underwent isolated bioprothestic MVR, mean age was 68±13, and females were the majority (58.4%). Most of these procedures were performed at teaching institutions (71.3%) and during an elective admission (64%). In-hospital mortality improved during the study period (7.8% in 2003 to 4.7% in 2014, p trend=0.016). Postoperative morbidities were common; permanent pacemaker 11.7%, stroke 2.4%, new dialysis 4.9% and blood transfusion 41.6%. Mean length of stay was 13±12 days, and 27.2% of patients were discharged to an intermediate care of rehabilitation facility. Cost of hospitalisation was

Comparative early outcomes of tricuspid Valve repair versus replacement for secondary tricuspid regurgitation

62 443±50 997. Conclusions Isolated bioprosthetic MVR for mitral regurgitation is performed infrequently but is associated with significant in-hospital morbidity and mortality and cost in contemporary practice. These data are useful as benchmarks for the evolving TMVR therapies.

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction

Background Comparative outcome data on tricuspid valve repair (TVr) versus tricuspid valve replacement (TVR) for severe secondary tricuspid regurgitation (TR) are limited. Methods We used a national inpatient sample to assess in-hospital morbidity and mortality, length of stay and cost in patients with severe secondary TR undergoing isolated TVr versus TVR. Results A total of 1364 patients (national estimate=6757) underwent isolated tricuspid valve surgery during the study period, of whom 569 (41.7%) had TVr and 795 (58.3%) had TVR. There was no difference in the prevalence of major morbidities between the two groups, except for liver disease and hepatic cirrhosis, which were more common in the TVR group. Before propensity matching, in-hospital mortality was similar between patients who underwent isolated TVr and TVR (8.1% vs 10.8%, p=0.093), but the incidence of postoperative morbidities differed: TVR was associated with higher rates of permanent pacemaker implantation and blood transfusion, while TVr was associated with more acute kidney injury. After rigorous propensity score matching, TVR was associated with significantly higher rates of in-hospital death (12% vs 6.9%, p=0.009) and permanent pacemaker implantation (33.7% vs 11.2%, p<0.001). Postoperative morbidities and length of stay, however, were not different between the two groups. Nonetheless, cost of hospitalisation was 16% higher in the TVr group. Conclusions In patients undergoing isolated surgery for secondary TR, TVR is associated with higher in-hospital mortality and need for permanent pacemaker compared with TVr. Further studies are needed to understand the impact of the type of surgery on the short-term and long-term mortality in this complex undertreated population.

Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention: Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention

BackgroundAcute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST-elevation myocardial infarction (STEMI). However, the impact of full-scale decompensated diabetes on STEMI outcomes has not been investigated.MethodsWe utilized the national inpatient sample (2003–2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). We compared in-hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity-score matching.ResultsA total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suffered DKA or HSS during the hospitalization. After propensity-score matching, DKA/HHS remained associated with a significant 32% increase in in-hospital mortality (25.6% vs. 19.4%, p = 0.001). The DKA/HHS group also had higher incidences of acute kidney injury (39.4% vs. 18.9%, p < 0.001), sepsis (7.3% vs. 4.9%, p = 0.022), blood transfusion (11.3% vs. 8.2%) and a non-significant trend towards higher incidence of stroke (3.8% vs. 2.4%, p = 0.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, p = 0.023), coronary stenting (26.1% vs. 34.8%, p < 0.001), or bypass grafting (6.2% vs. 8.7%, p = 0.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44-0.98, p = 0.039).ConclusionsDecompensated diabetes complicates ~ 1.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in-hospital morbidity and mortality and cost.

Incidence and Outcomes of Non-ST Elevation Myocardial Infarction in Patients Hospitalized with Decompensated Diabetes

To evaluate the safety and efficacy of switching to bivalirudin during primary percutaneous coronary intervention (PCI) for patients who received preprocedure unfractionated heparin (UFH).