Francesco Bedogni

Extracorporeal Ultrafiltration for the Treatment of Overhydration and Congestive Heart Failure

Fluid overload may occur in patients with congestive heart failure. Under normal conditions, this is treated with inotropic support and diuretics. However, when diuretics fail, fluid removal becomes uncontrolled and other therapeutic options must be undertaken. Extracorporeal ultrafiltration is a possible solution to restore a status of fluid balance close to normal. Several new technologies have made ultrafiltration available today in all centers and easy to be instituted. Acute isolated schedules of ultrafiltration may, however, be too aggressive and result in severe hemodynamic instability. For this reason, continuous extracorporeal techniques have been applied in such patients and the therapy is generally carried out with success. Excellent hemodynamic stability, a good cardiovascular response and often diuresis restoration are the most common effects encountered using continuous forms of extracorporeal fluid removal. The potential for a home-based application of these techniques represents a further stimulating concept to be investigated.

Troponin T, troponin I and creatine kinase-MB mass after elective coronary stenting.

Objective To assess whether and to what extent elective coronary stenting is associated with biochemical evidence of minor myocardial damage (MMD), as defined by the detection of abnormal post-procedural serum levels of one or more among the following markers of ischaemic injury: creatine kinase (CK)-MB mass, troponin T (Tn-T) and troponin I (Tn-I).Methods Nineteen elective procedures of coronary stenting were compared with a matched group of 25 conventional percutaneous transluminal coronary angioplasty (PTCA) procedures performed in our laboratory from March to June 1995. Cases with evolving or recent (< 2 weeks) myocardial infarction, chronic total occlusions and dilatation of saphenous vein grafts were excluded. By definition, all of the patients had undergone uneventful deployment of a single Palmaz-Schatz stent, with no chest pain and no persistent ECG changes after the procedure. Serum levels of CK-MB mass, Tn-T and Tn-I were determined at baseline and 6, 12 and 24 h after the procedure. The frequency of abnormal results was determined for each marker. Baseline and peak post-procedural levels in the two groups were compared and related to procedural variables.Results Baseline values were normal in all cases. The quantitative analysis showed that post-procedural levels of each marker (including total CK) were significantly higher with respect to baseline in both groups. In the stent group, two patients had positive CK-MB mass, four positive Tn-T and seven positive Tn-I. Absolute changes in Tn-T and Tn-I were closely related to changes in CK-MB mass (r = 0.76, P < 0.0001; r = 0.90, P < 0.0001, respectively). Three of these patients developed clinically silent side-branch occlusion. All of them were positive for troponins and two were positive for CK-MB. No correlation was found between procedural variables and the results of biochemical assays. In the PTCA group, three patients were positive for Tn-I, whereas the CK-MB mass and Tn-T remained constantly normal. No side-branch occlusion was observed. The peak CK-MB mass and Tn-I were significantly higher in the stent group than they were in the PTCA group (3.04 ± 4.1 versus 1.27 ± 1.3 ng/ml, P = 0.046; 0.78 ± 1.17 versus 0.28 ± 0.3 ng/ml, P = 0.046, respectively). This difference was no longer apparent when patients with side-branch occlusion were excluded.Conclusions In our series, Tn-I measurement shows the highest ability to detect MMD, being positive in 37% of stent and 14% of PTCA cases. Elective coronary stenting is associated with greater release of CK-MB mass and Tn-I than is conventional PTCA. This finding is mainly determined by cases of side branch occlusion, which account for most, but not all, periprocedural MMD in the stent group.

Ultrafiltration in Patients with Hypervolemia and Congestive Heart Failure

Fluid overload may occur in patients with myocardial dysfunction and different clinical problems. Myocoardial dysfunction may be a consequence of heart dilatation with reduced contractility, ventricular stiffness with diastolic dysfunction or the consequence of myocardial injury or circulating myocardial depressant factors as seen in sepsis. In all cases, cardiac support can be achieved by the optimization of fluid balance, the reduction in organ edema and the restoration of desirable levels of pre- and afterload. Several reports have shown that myocardial elastance can improve after hemofiltration with restoration of adequate fluid balance. In such conditions, continuous extracorporeal therapy may result in remarkable cardiovascular stability with maintenance of hemodynamic parameters, including mean arterial pressure, heart rate and systemic vascular resistance. Such stability, which is achieved through the slow continuous ultrafiltration and continuous refilling of the intravascular volume from the interstitium, enables the stability of the circulating blood volume and the preservation of organ perfusion. This is also crucial for renal recovery during acute renal failure.

Rescue PTCA for a Totally Occluded Left Main Coronary Artery in Acute Myocardial Infarction with Cardiogenic Shock: Technical Success and Long-Term Survival

Percutaneous transluminal coronary angioplasty was performed after failed thrombolysis in a 54-year-old man for total occlusion of the left main coronary artery in the setting of acute myocardial infarction with cardiogenic shock. The procedure was successful in terms of vessel recanalization and restoration of flow. The recovery of muscle function was limited due to the time lag between onset of symptoms and recanalization. This case highlights the crucial role of early identification and prompt referral of patients with extensive ischemia to centers with the capability for emergency percutaneous revascularization procedures.

“Valve in valve” implantation of two self-expandable transcatheter aortic valves in a patient with aortic root aneurysm and massive aortic regurgitation: “A new TAVI option”

Catheter‐based treatment of aortic regurgitation (AR) often proves challenging especially due to associated anatomical difficulties. Here, we present a case of CoreValve implantation with a novel use of the valve‐in‐valve technique to effectively treat severe AR in a patient with repeated cardiac surgery and aneurismatic prosthetic ascending aorta.

Radiofrequency Catheter Ablation of the Slow Reentrant Pathway of Sustained Ventricular Tachycardia

The article reports the cases of two patients with severe coronary artery disease and associated recurrent sustained ventricular tachycardia successfully treated with radiofrequency catheter ablation. In the first patient, two different types of ventricular tachycardia (one incessant) were eliminated. In all procedures, an area of slow conduction critical for tachycardia maintenance was localized by endocardial mapping techniques. Radiofrequency energy delivered to this area could permanently modify the anatomical substrate of the arrhythmia. After single follow‐ups of 19, 14, and 13 months regarding the arrhythmic entities, the patients are well and free from spontaneous recurrences.