David Ogilby

Acute Hemodynamic and Clinical Effects of Levosimendan in Patients With Severe Heart Failure

BackgroundWe determined the short-term hemodynamic and clinical effects of levosimendan, a novel calcium-sensitizing agent, in patients with decompensated heart failure. Methods and ResultsOne hundred forty-six patients with New York Heart Association functional class III or IV heart failure (mean left ventricular ejection fraction 21±1%) who had a pulmonary capillary wedge pressure ≥15 mm Hg and a cardiac index ≤2.5 L · min−1 · m−2 were enrolled in a multicenter, double-blind, placebo-controlled study and randomized 2:1 to intravenous infusion of levosimendan or placebo. Drug infusions were uptitrated over 4 hours from an initial infusion rate of 0.1 &mgr;g · kg−1 · min−1 to a maximum rate of 0.4 &mgr;g · kg−1 · min−1 and maintained at the maximal tolerated infusion rate for an additional 2 hours. Levosimendan caused dose-dependent increases in stroke volume and cardiac index beginning with the lowest infusion rate and achieving maximal increases in stroke volume and cardiac index of 28% and 39%, respectively. Heart rate increased modestly (8%) at the maximal infusion rate and was not increased at the 2 lowest infusion rates. Levosimendan caused dose-dependent decreases in pulmonary capillary wedge, right atrial, pulmonary arterial, and mean arterial pressures. Levosimendan appeared to improve dyspnea and fatigue, as assessed by the patient and physician, and was not associated with a significant increase in adverse events. ConclusionsLevosimendan caused rapid dose-dependent improvement in hemodynamic function in patients with decompensated heart failure. These hemodynamic effects appeared to be accompanied by symptom improvement and were not associated with a significant increase in the number of adverse events. Levosimendan may be of value in the short-term management of patients with decompensated heart failure.

Safety, Effectiveness, and Outcomes of Cardiac Catheterization in Nonagenarians

With an aging population, nonagenarians (≥90 years of age) are increasingly being considered for cardiac catheterization. Because of the paucity of outcomes data in this population, we sought to evaluate the acute and intermediate outcomes of nonagenarians undergoing cardiac catheterization. A retrospective cohort of 44 nonagenarians undergoing 53 cardiac catheterizations from 2002 to 2010 was identified. Mean age was 91 years (range 90 to 96) with 57% of patients being women. Thirteen percent presented with ST-segment elevation myocardial infarction, 32% with non-ST-segment elevation myocardial infarction, 14% with unstable angina, 25% with chronic angina, and 16% with aortic stenosis. Eighteen percent had left main coronary artery disease and 73% had multivessel coronary disease. Complications occurred in 6 of 44 patients (3 with acute kidney injury, 2 with atrial fibrillation, 1 with femoral artery pseudoaneurysm). Twenty patients were treated with medical management, 1 patient underwent coronary artery bypass surgery, and 2 patients underwent aortic valve replacement. Twenty-one patients underwent percutaneous coronary intervention in 27 different vessels. There was procedural success in 93% of these patients. There were no major adverse cardiac events. Five complications occurred after the intervention (4 atrial fibrillations, 1 femoral artery pseudoaneurysm). Cumulative mortalities at 1 month and 6 and 12 months were 0%, 9%, and 20% respectively. In patients who underwent percutaneous coronary intervention or surgery, mortalities were 0%, 0%, and 13% at 1 month and 6 and 12 months, respectively.

Monitoring left ventricular function using an ambulatory nuclear device during esophageal motility testing: preliminary observations in patients with chest pain syndrome but normal coronary angiograms

The nonimaging ambulatory nuclear device which allows continuous monitoring of LV ejection fraction (EF), relative LV volume, and electrocardiographic changes was used serially to study changes during exercise, ice immersion, and provocative esophageal motility studies with edrophonium (Tensilon) and Bernstein tests. Thus, (1) routine baseline and provocative esophageal motility studies result in a low but definite yield of positive results (12.5%) in patients with chest pains and normal coronary angiograms, and (2) there is no significant change in LV function during provocative esophageal motility studies with eigher Tensilon or Bernstein test