Eric Stoupel

Myocardial Homing of Nonmobilized Peripheral‐Blood CD34+ Cells After Intracoronary Injection

Granulocyte– colony‐stimulating factor administered for autologous hematopoietic stem cell isolation from blood may favor restenosis in patients implanted after acute myocardial infarction (AMI). We therefore tested the isolation of peripheral‐blood CD34+ cells without mobilization in six patients with AMI. After large‐volume cytapheresis and positive CD34+ cell selection, 3.6 to 27.6 million CD34+ cells were obtained. We performed intra‐coronary implantation of these cells and recorded no restenosis or arrhythmia. We used positron emission tomography (PET) to assess myocardial‐labeled CD34+ cell homing, which accounted for 5.5% of injected cells 1 hour after implantation. In conclusion, large amounts of CD34+ cells, in the range reported in previous studies, can be obtained from nonmobilized peripheral blood. PET with [18F]‐fluorodeoxyglucose cell labeling is an efficient imaging method for homing assessment.

Robotic-enhanced biventricular resynchronization: An alternative to endovenous cardiac resynchronization therapy in chronic heart failure

BACKGROUND Cardiac resynchronization therapy (CRT) by pacing the left and right ventricles is an emerging option for treatment of severe heart failure with ventricular conduction disturbances. Stimulation through a coronary vein is currently the technique of choice to achieve left ventricular (LV) pacing. Unfortunately, this approach carries significant limitations and drawbacks. Therefore we explored robotic-enhanced thoracoscopic implantation of an epicardial lead as an alternative technique to stimulate the LV in cardiac resynchronization therapy. METHODS A total of 15 patients were included in this study. Right (atrial and ventricular) leads were implanted classically through the left subclavian vein. Robotic-enhanced thoracoscopy was then performed to implant the LV epicardial lead. RESULTS Of the 15 patients, 13 underwent successful endoscopic robotic cardiac resynchronization therapy. Two patients underwent conversion to a small thoracotomy. No perioperative complication occurred in the patients who did not undergo conversion. Acute and chronic LV lead thresholds were satisfactory in all patients, improving over time. All were subjectively and objectively improved at 4 months. As compared with conventional methods, the procedural cost was not significantly affected. CONCLUSIONS Based on this feasibility study, we believe that robotic LV epicardial lead implantation is a valuable option to achieve biventricular resynchronization therapy. It allows for more reproducible acute thresholds for LV pacing and sensing than does the percutaneous approach; enables fine tuning of the LV lead position, thus potentially providing optimal hemodynamic benefit; and avoids the pitfalls and limitations of the endovenous approach. Therefore it deserves further prospective studies to assess its place in the therapeutic armamentarium against heart failure.

Primary Cardiac Lymphoma: Diagnosis by Transvenous Biopsy Under Transesophageal Echocardiographic Guidance

A 64-year-old woman presenting with dizziness and atrioventricular conduction disturbances was found to have a right atrial mass by two-dimensional transthoracic echocardiography. Transesophageal echocardiography allowed further delineation of the tumor and safe performance of transvenous biopsy, thereby obviating the need for surgery. Pathological examination of the biopsy specimen as well as the absence of extracardiac location established the diagnosis of primary cardiac lymphoma.

Pulmonary vein isolation by robotic-enhanced thoracoscopy for symptomatic paroxysmal atrial fibrillation.

BACKGROUND Pulmonary vein isolation (PVI) has been shown to be effective treatment of patients with symptomatic paroxysmal atrial fibrillation (PAF). The percutaneous approach is currently the technique of choice. Unfortunately, this procedure has limitations and complications that lead to fluctuating success rates. We explored an alternative technique of robotic-enhanced, closed-chest PVI with an endoscopic microwave-based catheter. METHODS Seven symptomatic PAF patients were included in the study. The pulmonary veins were isolated through right (only) robotic-enhanced thoracoscopy on the beating heart. RESULTS Six patients underwent successful endoscopic PVI. In 1 patient the operation was converted into small right thoracotomy. Operative assessment of the ablation line showed a successful electric block in every patient. Three months after the procedure, the first 5 patients were in permanent sinus rhythm. The 2 other patients had AF but had less frequent and less symptomatic episodes compared with the preoperative situation. CONCLUSIONS On the basis of this preliminary experience, we believe that in the near future endoscopic right-chest robotic-enhanced PVI on the beating heart may become a valid option in the treatment of symptomatic PAF patients. This procedure allows for more-reproducible ablation lines and may avoid many of the pitfalls and drawbacks of the percutaneous approach. Therefore this technique deserves larger prospective evaluation in the treatment of AF.

Atrial septostomy under transesophageal guidance in a patient with primary pulmonary hypertension and absent right superior vena cava

A patient presenting primary pulmonary hypertension and absent right superior vena cava underwent blade/balloon atrial septostomy as palliative therapy. Due to the anomaly of the venous drainage system, only transesophageal echocardiography allowed the performance of the maneuvre.

The new long-acting coronary artery dilator molsidomine and its metabolite SIN-1

We studied the effects of intracoronary injections of SIN-1 (0.8 mg), the active metabolite of molsidomine, on coronary artery diameters and coronary stenoses. In nine patients with abnormal angiograms measurements were made 4 and 8 minutes after SIN-1 administration. There was a statistically significant increase in coronary luminal diameter in proximal, medial, and distal segments as well as at the level of the stenoses. At 4 minutes after administration distal segments showed a mean increase in diameter of 50%, compared to a mean increase of 26% in proximal segments. In six patients with normal angiograms SIN-1 abolished three of four coronary spasms induced by ergonovine maleate. A protective effect of SIN-1 against the vasoconstrictor effects of ergonovine was still present at 8 minutes after administration. Heart rate and blood pressure remained unchanged throughout the study. We conclude that the vasodilation induced by SIN-1 in normal and stenotic coronary arteries is probably an important contribution to the antianginal efficacy of molsidomine and suggests that molsidomine may be effective in the prophylaxis of variant angina.

Effect of oral sustained-release nitroglycerin on exercise capacity in angina pectoris: Dose-response relation and duration of action during double-blind crossover randomized acute therapy

Ten men with documented coronary artery disease and stable exertional angina underwent a double-blind crossover study to examine the benefit and the duration of action on their symptom-limited exercise capacity of 2 doses (2.5 and 6.5 mg) of sustained-release nitroglycerin (SRNG). A multistage bicycle test was performed in the sitting position by steps of 30 W each 3 minutes until the onset of typical angina pectoris. It was performed 24 hours before the start of the study; 1 and 5 hours after administration of placebo, and repeated after 2.5 and 6.5 mg of SRNG administered in a double-blind crossover study according to a 4 successive days protocol. No differences appeared between administration of placebo (1 and 5 hours) and the results obtained at the first exercise test. The dose of 2.5 mg of SRNG was effective on the symptom-limited working capacity but only at 1 hour (+9%; p less than 0.01). The dose of 6.5 mg was more effective both at 1 hour (+25%; p less than 0.001) and at 5 hours (+27%; p less than 0.001). All patients had angina at a higher heart rate (+5 to 8%; p = NS [not significant] and p less than 0.01), whereas systolic blood pressure and double product tended to be slightly but insignificantly increased. S-T depression at the onset of angina was insignificantly changed with placebo, and 2.5 and 6.5 mg of SRNG. It is concluded that 6.5 mg of orally administered SRNG is effective during at least 5 hours, and that the magnitude of the benefit and its duration are dose-related.

Analysis of Exercise-Induced R-Wave-Amplitude Changes in Detection of Coronary Artery Disease in Patients with Typical or Atypical Chest Pain under Digitalis Treatment

Specificity and sensitivity of exercise ECG were compared to exercise stress thallium 201 scanning and coronary arteriograms in 70 male patients with typical or atypical chest pain complaints, without previous myocardial infarction. 50 patients (group I) did not receive any treatment; 20 patients (group II) received digitalis as preventive treatment of atrial arrhythmias or for no particular reason. Only subjects with concordant results in radionuclide and angiography examinations were considered as coronary artery disease patients. Exercise stress tests were performed sitting on the bicycle ergometer using a progressive loading profile (30 W for 3 min), to the symptom-limited capacity (VO2SL). Positive exercise ECG were confirmed on ST decrease (1.5 mm) or on absence or increase in R-wave-amplitude modifications (V5). In the group I patients, ECG-ST-modification sensitivity, specificity, predictive value (+) and efficiency were, respectively, 92, 82, 86 and 88%. R-wave-variation sensitivity, specificity, predictive value (+) and efficiency were, respectively, 41, 74, 65 and 56%. In the group II patients, ST-depression sensitivity, specificity, predictive value (+) and efficiency were, respectively, 100, 33, 59 and 65%. R-wave-variation sensitivity, specificity, predictive value (+) and efficiency were, respectively, 50, 70, 63 and 60%. It was concluded that R-wave-amplitude variations induced lower false positive responses than ST-segment depression in patients under digitalis treatment. False negative responses were unfortunately 50% using the R-wave criterion. Exercise ECG was finally judged as a poor indicator of CAD in patients under digitalis treatment.

Efficacy of Intravenous Disopyramide in Acute Cardiac Arrhythmias

SummaryThe efficacy of intravenous disopyramide was studied during 200 episodes of supraventricular and ventricular arrhythmias in 160 patients, mainly presenting with acute myocardial infarction or cardiac failure. Disopyramide 50 mg was administered in a few seconds and any remaining dose within 2 to 5 min. The overall success rate was 80.5%. Intravenous disopyramide was more effective in patients with ventricular arrhythmias (85%) than in those with supraventricular arrhythmias (76%). Dose dependent prolongation of the PR interval, QRS time and the QT interval occurred in 16.32 and 20% of the cases, respectively. The adverse effects were aggravation of the arrhythmias, decrease of blood pressure and anticholinergic activity.

Effects of molsidomine on left ventricular dimensions and cardiac function in patients with chronic heart failure.

The effects of molsidomine were studied in seven patients with refractory congestive heart failure by means of two-dimensional echocardiography. Four milligrams of molsidomine or placebo was sublingually administered in a double-blind crossover manner. End-diastolic dimension, end-systolic dimension, and mean velocity of circumferential fiber shortening were measured just below the mitral valve before drug or placebo administration and 1 hour later. No significant changes were observed with placebo. Heart rate and mean arterial pressure were not significantly modified with Molsidomine (80 to 83 bpm and 100 to 97 mm Hg, respectively). The reduction in end-diastolic dimension (67 to 61 mm; 9%; P less than 0.01) was slightly greater than the decline in end-systolic dimension (59 to 54 mm; 8%; p less than 0.01). The mean velocity of circumferential fiber shortening increased from 0.4 to 0.5 sec-1 but did not achieve statistical significance. Thus sublingual administration of molsidomine in patients with chronic heart failure reduces end-diastolic more than end-systolic dimension without effect on blood pressure, suggesting a predominant action on cardiac preload.