Mauro Maioli

Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars

BACKGROUND Many believe that dyskinesia is the only predictor of favorable surgical outcome after large myocardial infarction and that akinetic scars do not recover well in patients with globally depressed ventricular function. METHODS This study evaluates clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n = 51) or large dyskinetic scar (n = 49) and depressed left ventricular function (ejection fraction <30%). Groups were comparable for symptoms, indication for operation, and delay from myocardial infarction. Heart failure was a major indication for operation in both groups. Coronary grafting was performed in 98% of patients: 10 had mitral valve repair or replacement, and 47 patients with preoperative ventricular arrhythmias had cryotherapy. In-hospital mortality was 12% (five patients in the akinetic group [10%] and seven in the dyskinetic group [14%]). RESULTS Results showed an early and late improvement in New York Heart Association functional class and ejection fraction (from 23% +/- 5% to 31% +/- 11% to 40% +/- 13% in akinetic patients and from 23% +/- 6% to 41% +/- 10% to 41% +/- 12% in dyskinetic patients). Ventricular tachycardia was reduced significantly in both groups early and late after the operation. CONCLUSION We conclude that in patients with either large akinetic or dyskinetic scar and severe left ventricular dysfunction, endoventricular circular patch plasty associated with coronary grafting and cryotherapy, when indicated, provides surviving patients with significant improvement in cardiac function. This approach can be considered as an alternative to heart transplantation in patients with severe left ventricular dysfunction.

Sodium Bicarbonate Versus Saline for the Prevention of Contrast-Induced Nephropathy in Patients With Renal Dysfunction Undergoing Coronary Angiography or Intervention

OBJECTIVES The purpose of this study was to compare the efficacy of sodium bicarbonate versus isotonic saline in addition to N-acetylcysteine (NAC) to prevent contrast-induced nephropathy (CIN) in a larger population of patients with renal dysfunction undergoing coronary angiography or intervention. BACKGROUND Contrast-induced nephropathy accounts for more than 10% of hospital-acquired renal failure. Recent studies suggest that hydration with sodium bicarbonate is more protective than isotonic saline in the prevention of CIN. METHODS The prospective, single center study included 502 patients with estimated creatinine clearance <60 ml/min, randomized to receive infusion of either saline or sodium bicarbonate before and after iso-osmolar contrast medium administration. All patients received oral NAC 600 mg twice a day. Contrast-induced nephropathy was defined as an absolute increase of serum creatinine > or =0.5 mg/dl measured within 5 days. RESULTS Contrast-induced nephropathy occurred in 54 patients (10.8%); 25 (10%) were treated with sodium bicarbonate and 29 (11.5%) with saline (p = 0.60). In patients with CIN, the mean increase in creatinine was not significantly different in the 2 study groups (0.9 +/- 0.6 mg/dl vs. 0.7 +/- 0.2 mg/dl, respectively; p = 0.15). Only 2 patients needed temporary hemofiltration. CONCLUSIONS Hydration with sodium bicarbonate plus NAC before contrast medium exposure is not more effective than hydration with isotonic saline plus NAC for prophylaxis of CIN in patients with moderate-to-severe renal dysfunction. (Sodium Bicarbonate Versus Saline for the Prevention of Contrast-Induced Nephropathy; NCT00606827).

Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle

This study reports hemodynamic, electrophysiologic, and clinical results in 171 patients (157 men and 14 women, mean age 57 +/- 8 years) 1 year after endoventricular circular patch repair and coronary grafting for postinfarction left ventricular dyskinetic or akinetic aneurysm. All patients had hemodynamic and electrophysiologic study before the operation and early and 1 year after the operation. The vast majority of aneurysms were anterior (n = 166), with a mean delay from infarction of 43 +/- 50 months. Fifty-two percent of patients were in New York Heart Association class III or IV, and preoperative ejection fraction was less than 40% in the majority of them (75%). Preoperative clinical ventricular tachycardia was present in 25 patients and was inducible in 59 patients. All patients had endoventricular circular patch repair with a synthetic (n = 99) or autologous patch (n = 72); 96% had associated coronary grafting with a mean number of bypass grafts of 1.9 +/- 0.9. Results at 1 year demonstrated a significant increase in ejection fraction (from 36% +/- 13% to 46% +/- 12% (p < 0.0001) and a significant reduction in ventricular volumes (end-diastolic volume index from 116 +/- 5 to 94 +/- 29 ml/m2 and end-systolic volume index from 77 +/- 45 to 53 +/- 25 ml/m2, p < 0.0001). New York Heart Association functional classification was significantly improved (2.6 +/- 0.9 vs 1.4 +/- 0.6, p < 0.0001) and ventricular tachycardias were almost suppressed (no documented clinical ventricular tachycardias and 8% incidence of inducible ventricular tachycardias after 1 year, chi 2 < 0.001). Patients who benefit most from the operation are those with more severe preoperative left ventricular dysfunction (i.e., ejection fraction < 30%), more frequent ventricular arrhythmias, and larger ventricular volumes. At regression analysis, critical disease of the right coronary artery was the only independent predictor of unsatisfactory pump improvement (as evaluated by postoperative increase of ejection fraction < 10 absolute points). In conclusion, in our large series of patients operated on by one surgical team between 1988 and 1993, who were studied hemodynamically both before and after the operation, endoventricular circular patch repair of left ventricular aneurysm associated with coronary grafting definitely improves left ventricular pump function and clinical status 1 year after the operation.

Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair.

OBJECTIVES This retrospective study attempted to relate surgical outcome with the extent and type of preoperative wall motion asynergy in patients with postinfarction myocardial scar who underwent endoventricular circular patch plasty repair and associated coronary grafting. BACKGROUND Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic scar, and previous studies have reported that the absence of paradoxic systolic motion correlates with higher operative mortality and no improvement in pump function. METHODS Two hundred forty-five patients who underwent endoventricular circular patch plasty repair and associated coronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation. All had right and left cardiac catheterization. The centerline method was applied to preoperative right anterior oblique LV angiography to assess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening <2 SD from the normal mean value (extent of asynergy ([A%]). RESULTS The overall perioperative mortality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all the clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a higher perioperative mortality rate (12%) than patients with a small scar (2.2%). After the operation, the ejection fraction (EF) increased from 36 +/- 13% to 50 +/- 13% (mean +/- SD), and pulmonary pressures significantly decreased. End-diastolic volume decreased from 199 +/- 75 to 89 +/- 36 ml/m2. Patients with a large akinetic scar had the most severely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressive improvement in function (EF from 25 +/- 9% to 41 +/- 12%), not different from that observed with large dyskinetic scarring (EF from 26 +/- 7% to 46 +/- 11%). CONCLUSIONS Surgical outcome of endoventricular circular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence of dyskinesia. Patients with a large akinetic scar and severely depressed pump function benefit from a relatively simple surgical procedure previously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, and the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function.

Early glycoprotein IIb–IIIa inhibitors in primary angioplasty (EGYPT) cooperation: an individual patient data meta-analysis

Background: Even though time-to-treatment has been shown to be a determinant of mortality in primary angioplasty, the potential benefits from early pharmacological reperfusion by glycoprotein (Gp) IIb–IIIa inhibitors are still unclear. The aim of this meta-analysis was to combine individual data from all randomised trials conducted on facilitated primary angioplasty by the use of early Gp IIb–IIIa inhibitors. Methods and results: The literature was scanned by formal searches of electronic databases (MEDLINE, EMBASE) from January 1990 to October 2007. All randomised trials on facilitation by the early administration of Gp IIb–IIIa inhibitors in ST-segment elevation myocardial infarction (STEMI) were examined. No language restrictions were enforced. Individual patient data were obtained from 11 out of 13 trials, including 1662 patients (840 patients (50.5%) randomly assigned to early and 822 patients (49.5%) to late Gp IIb–IIIa inhibitor administration). Preprocedural Thrombolysis in Myocardial Infarction Study (TIMI) grade 3 flow was more frequent with early Gp IIb–IIIa inhibitors. Postprocedural TIMI 3 flow and myocardial blush grade 3 were higher with early Gp IIb–IIIa inhibitors but did not reach statistical significance except for abciximab, whereas the rate of complete ST-segment resolution was significantly higher with early Gp IIb–IIIa inhibitors. Mortality was not significantly different between groups, although early abciximab demonstrated improved survival compared with late administration, even after adjustment for clinical and angiographic confounding factors. Conclusions: This meta-analysis shows that pharmacological facilitation with the early administration of Gp IIb–IIIa inhibitors in patients undergoing primary angioplasty for STEMI is associated with significant benefits in terms of preprocedural epicardial recanalisation and ST-segment resolution, which translated into non-significant mortality benefits except for abciximab.

Usefulness of Atorvastatin (80 mg) in Prevention of Contrast-Induced Nephropathy in Patients With Chronic Renal Disease

We investigated the efficacy of short-term high-dose atorvastatin in decreasing the risk of contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) subjected to coronary angiography and/or angioplasty. CIN occurs in up to 15% of patients with pre-existing CKD and affects clinical outcome. The protective effect of statin therapy against CIN is still controversial. A prospective, single-center study of 304 patients with baseline estimated creatinine clearance <60 ml/min were randomized to receive atorvastatin 80 mg/day or placebo for 48 hours before and 48 hours after contrast medium administration. All patients received intravenous saline hydration and oral N-acetylcysteine 1,200 mg 2 times/day. Iso-osmolar contrast medium was used. CIN was defined as an absolute increase of serum creatinine > or = 0.5 mg/dl within 5 days after the procedure. CIN occurred in 31 patients (10%), 16 (11%) in the placebo group and 15 (10%) in the atorvastatin group (p = 0.86). Mean increase in creatinine was not significantly different in the 2 groups (0.59 + or - 0.17 in placebo group vs 0.72 + or - 0.26 mg/dl in atorvastatin group, p = 0.31). Persistent kidney injury, defined as 1-month increase from baseline creatinine value > or = 25%, was observed in 30% in the placebo group and in 31% in the atorvastatin group (p = 0.58). In conclusion, a short-term administration of high doses of atorvastatin before and after contrast exposure, in addition to standard intravenous hydration and oral N-acetylcysteine, does not decrease CIN occurrence in patients with pre-existing CKD.

Early glycoprotein IIb-IIIa inhibitors in primary angioplasty-abciximab long-term results (EGYPT-ALT) cooperation: individual patient's data meta-analysis.

Summary.  Background: Even although time to treatment has been shown to be a determinant of mortality in primary angioplasty, the potential benefits are still unclear from early pharmacological reperfusion by glycoprotein (Gp) IIb‐IIIa inhibitors. Therefore, the aim of this meta‐analysis was to combine individual data from all randomized trials conducted on upstream as compared with late peri‐procedural abciximab administration in primary angioplasty. Methods: The literature was scanned using formal searches of electronic databases (MEDLINE and EMBASE) from January 1990 to December 2010. All randomized trials on upstream abciximab administration in primary angioplasty were examined. No language restrictions were enforced. Results: We included a total of seven randomized trials enrolling 722 patients, who were randomized to early (n = 357, 49.4%) or late (n = 365, 50.6%) peri‐procedural abciximab administration. No difference in baseline characteristics was observed between the two groups. Follow‐up data were collected at a median (25th–75th percentiles) of 1095 days (720–1967). Early abciximab was associated with a significant reduction in mortality (primary endpoint) [20% vs. 24.6%; hazard ratio (HR) 95% confidence interval (CI) = 0.65 (0.42–0.98) P = 0.02, Phet = 0.6]. Furthermore, early abciximab administration was associated with a significant improvement in pre‐procedural thrombolysis in myocardial infarction (TIMI) 3 flow (21.6% vs. 10.1%, P < 0.0001), post‐procedural TIMI 3 flow (90% vs. 84.8%, P = 0.04), an improvement in myocardial perfusion as evaluated by post‐procedural myocardial blush grade (MBG) 3 (52.0% vs. 43.2%, P = 0.03) and ST‐segment resolution (58.4% vs. 43.5%, P < 0.0001) and significantly less distal embolization (10.1% vs. 16.2%, P = 0.02). No difference was observed in terms of major bleeding complications between early and late abciximab administration (3.3% vs. 2.3%, P = 0.4). Conclusions: This meta‐analysis shows that early upstream administration of abciximab in patients undergoing primary angioplasty for ST‐segment elevation myocardial infarction (STEMI) is associated with significant benefits in terms of pre‐procedural epicardial re‐canalization and ST‐segment resolution, which translates in to significant mortality benefits at long‐term follow‐up.

Increase of myocardial salvage and left ventricular function recovery with intracoronary abciximab downstream of the coronary occlusion in patients with acute myocardial infarction treated with primary coronary intervention

In this prospective randomized trial on patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI), we hypothesized that abciximab administered intracoronarily, downstream of the coronary occlusion, leads to a greater degree of myocardial salvage and better left ventricular function recovery compared with the usual abciximab administration. Forty‐five consecutive patients with first AMI and infarct‐related artery TIMI flow 0–1 undergoing primary PCI were enrolled. Twenty‐two patients were randomly assigned to the intracoronary treatment and 23 to the usual treatment. The initial perfusion defect, final infarct size, myocardial salvage, salvage index, and left ventricular function recovery were assessed by serial scintigraphic scans performed at admission and 7 days and 1 month after PCI. Angiographic myocardial blush grade, corrected TIMI frame count, and electrocardiographic ST segment elevation reduction were also assessed as markers of myocardial reperfusion. Final infarct size was significantly smaller (P = 0.043) and salvage index significantly higher (P = 0.003) in the intracoronary treatment group as a result of a greater degree of myocardial salvage (P = 0.0001). The increase of left ventricular ejection fraction at 1 month was significantly higher in the intracoronary treatment patients (P = 0.013). The markers of myocardial reperfusion were also significantly better in the intracoronary treatment group. In patients with AMI and occluded infarct‐related artery treated with primary PCI, intracoronary abciximab given just before PCI downstream of the occlusion is associated to a greater degree of myocardial salvage than the usual abciximab protocol. This benefit is mainly related to a substantial reduction in final infarct size, which leads to an improvement in left ventricular ejection fraction. Catheter Cardiovasc Interv 2004;62:186–192.

Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope ☆ ☆☆ ★

BACKGROUND Head-up tilt testing is extensively used to determine the vasovagal origin of syncope in patients with otherwise unexplained loss of consciousness, although issues remain regarding the method of the test. The diagnostic value of a shortened head-up tilt test potentiated with sublingual nitroglycerin was assessed in patients with unexplained syncope. METHODS Two hundred two patients (mean age 49+/-19 years) with syncope of unknown origin and 34 subjects in a control group (mean age 45+/-17 years) were studied. The patients and the subjects in the control group were tilted upright to 60 degrees for 20 minutes. If syncope did not occur, sublingual nitroglycerin (400 microg) was administered, and observation was continued for 25 more minutes. RESULTS During the unmedicated phase syncope occurred in 22 (11%) patients and in one member of the control group. After nitroglycerin was administered, syncope occurred in 119 (59%) patients and in 1 (3%) member of the control group. False-positive response (exaggerated response) was observed in eight (4%) patients and in four (12%) subjects in the control group. The total positivity rate of the test was 70% with a specificity rate of 94%. CONCLUSIONS Short-duration head-up tilt test potentiated with sublingual nitroglycerin provides an adequate specificity and positivity rate in patients with unexplained syncope.

Persistent Renal Damage after Contrast-Induced Acute Kidney Injury: Incidence, Evolution, Risk Factors and Prognosis

Background— The temporal evolution of renal function in patients with acute kidney injury after contrast medium (CI-AKI) is not well known. The aim of this observational study was to evaluate the incidence, risk factors, and prognostic implications of persistent renal damage (RD) in patients with preexistent moderate-to-severe renal dysfunction. Methods and Results— From June 2003 to March 2008, 3986 patients underwent coronary angiography at our institution; 1490 of 3986 had an estimated creatinine clearance of <60 mL/min and were enrolled. CI-AKI was defined as an absolute increase ≥0.5 mg/dL over baseline serum creatinine within 3 days after the administration of contrast medium (iodixanol). In patients who developed CI-AKI, persistent RD was defined as a relative decrease of creatinine clearance ≥25% over baseline at 3 months. Patients whose creatinine clearance returned to baseline (or nearly) were classified as transient RD. The overall incidence of CI-AKI was 12.1%, and persistent RD occurred in 18.6% of CI-AKI patients. At Cox regression analysis, nephropathy risk score ≥17, left ventricular ejection fraction ⩽30%, and increased value of serum creatinine ≥1.5-fold from baseline within 5 days were found to be significant risk factors for persistent RD. At 5 years, the incidence of death was significantly higher in patients with persistent RD than in both patients with transient RD (P=0.015) and those without CI-AKI (P=0.0001). A similar trend was observed for the combined end point of death, dialysis and cardiovascular events. Conclusions— These results suggest that CI-AKI is not always a transient, benign creatininopathy, but rather a direct cause of worsening renal function. The occurrence of CI-AKI can identify patients at increased risk of cardiovascular events.Background— The temporal evolution of renal function in patients with acute kidney injury after contrast medium (CI-AKI) is not well known. The aim of this observational study was to evaluate the incidence, risk factors, and prognostic implications of persistent renal damage (RD) in patients with preexistent moderate-to-severe renal dysfunction. Methods and Results— From June 2003 to March 2008, 3986 patients underwent coronary angiography at our institution; 1490 of 3986 had an estimated creatinine clearance of <60 mL/min and were enrolled. CI-AKI was defined as an absolute increase ≥0.5 mg/dL over baseline serum creatinine within 3 days after the administration of contrast medium (iodixanol). In patients who developed CI-AKI, persistent RD was defined as a relative decrease of creatinine clearance ≥25% over baseline at 3 months. Patients whose creatinine clearance returned to baseline (or nearly) were classified as transient RD. The overall incidence of CI-AKI was 12.1%, and persistent RD occurred in 18.6% of CI-AKI patients. At Cox regression analysis, nephropathy risk score ≥17, left ventricular ejection fraction ≤30%, and increased value of serum creatinine ≥1.5-fold from baseline within 5 days were found to be significant risk factors for persistent RD. At 5 years, the incidence of death was significantly higher in patients with persistent RD than in both patients with transient RD ( P =0.015) and those without CI-AKI ( P =0.0001). A similar trend was observed for the combined end point of death, dialysis and cardiovascular events. Conclusions— These results suggest that CI-AKI is not always a transient, benign creatininopathy, but rather a direct cause of worsening renal function. The occurrence of CI-AKI can identify patients at increased risk of cardiovascular events. # Clinical Perspective {#article-title-35}