Quintilio Caretta

The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularization: A comprehensive meta-analysis

AIMS Despite the recommendations of the current guidelines, scientific evidence continue to challenge the effectiveness of intra-aortic balloon pump (IABP) in acute myocardial infarction (AMI) complicated by cardiogenic shock. Moreover, 2 recent meta-analyses showed contrasting results. The aim of this study is to test the effect of IABP according to the type of therapeutic treatment of AMI: percutaneous coronary intervention (PCI), thrombolytic therapy (TT), or medical therapy without reperfusion. Articles published from January 1, 1986, to December 31, 2012, were collected and analyzed by meta-analysis. METHODS AND RESULTS We evaluated the IABP impact on inhospital mortality, on safety end points (stroke, severe bleeding) and long-term survival, using risk ratio (RR) and risk difference (RD) estimates. We found that the risk of death was (i) not significantly different between the IABP and control groups (RR 0.95, P = .52; RD -0.04, P = .28), (ii) significantly reduced in the TT subgroup (RR 0.77, P < .0001; RD -0.16, P < .0001), and (iii) significantly increased in the PCI subgroup (RR 1.18, P = .01; RD 0.07, P = .01). There were no significant differences in secondary end points (P, not significant). In addition, we compared the meta-analyses collected over the same search period. CONCLUSION The results show that IABP support is significantly effective in TT reperfusion but is associated with a significant increase of the inhospital mortality with primary PCI. The comparison of the meta-analyses demonstrates the key role of analysing primary clinical treatments to avoid systematic errors.

Low-dose dobutamine echocardiography predicts the early response of dysfunctioning myocardial segments to coronary artery bypass grafting.

Dobutamine echocardiography has recently been introduced for use in identification of viable myocardium in patients with acute myocardial infarction and prediction of the response of dysfunctioning myocardial segments to coronary angioplasty. The aim of this study was to evaluate whether this test may be used to predict the early response of dysfunctioning myocardial segments to surgical revascularization. We studied 30 patients with three-vessel disease and chronic, stable angina pectoris during coronary artery bypass grafting (CABG). Patients were monitored by intraoperative transesophageal echocardiography in the transgastric short-axis view at the papillary muscle level. The left ventricle was divided into eight segments; and 240 myocardial segments were analyzed. Percentage of systolic wall thickening (PSWT) was calculated in each segment at baseline (early after pericardiectomy), before bypass during dobutamine infusion (5 micrograms/kg/min), and after separation from cardiopulmonary bypass. Segments showing PSWT < 30% at baseline were considered dysfunctional. Segments showing an increase in PSWT > 10% during dobutamine infusion were considered responders. Segments showing an increase in PSWT < 10% during dobutamine infusion were considered nonresponders. At baseline, 161 (67%) of 240 segments had PSWT < 30% (dysfunctioning segments). During dobutamine, 98 (60%) of these segments increased PSWT > 10% (from 11.3% +/- 7.6% to 24.2% +/- 12.0%, p < 0.01; responder segments), and 63 (40%) increased PSWT < 10% (from 10.2% +/- 4.9% to 8.3% +/- 5.5%, p value not significant [NS]; nonresponder segments).(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection.

Objective In patients undergoing surgical repair of aortic dissection, false lumen perfusion during cardiopulmonary bypass may produce central nervous system damage, myocardial ischemia, aortic rupture, and death. We describe a method to detect false lumen perfusion at the beginning of retrograde aortic perfusion that may prevent these complications. Design Sonicated albumin microbubbles (8 mL) were injected through a side branch of the extracorporeal circulation line to detect true lumen and/or false lumen perfusion of the thoracic aorta at the beginning of cardiopulmonary bypass. Transesophageal echocardiography was used to image aortic perfusion. Setting The study was performed in a cardiac surgery theater. Patients A total of 27 consecutive patients undergoing operation for Type I aortic dissection were studied. Interventions All patients underwent surgical repair of aortic dissection and retrograde aortic perfusion through one femoral artery. Measurements and Main Results Patients were divided into three groups: Group I, those having adequate true lumen perfusion: brisk appearance and washout of contrast in the true lumen with no, poor, or delayed opacification of the false lumen; Group II, those having mixed true lumen and false lumen perfusion: simultaneous opacification of both lumens; Group III, those having inappropriate false lumen perfusion: same criteria as for adequate true lumen perfusion applied to the false lumen. The true lumen was perfused in 13 patients, both lumens in 11 patients, and false lumen alone in three patients. In these three patients, cannulation was repeated through the contralateral femoral artery with restoration of true lumen perfusion; the first patient died of diffuse cerebral ischemic damage and renal failure, another one experienced temporary postoperative monoparesis, and the last had no neurologic sequelae. Conclusions Contrast echocardiography allows immediate detection of retrograde aortic perfusion during cardiopulmonary bypass and may help prevent neurologic complications and death in patients with Type I dissection.

Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenic shock: a comprehensive meta-analysis of randomised trials and observational studies.

BACKGROUND Although controversial, using prophylactic intra-aortic balloon pump (IABP) in patients undergoing high-risk percutaneous coronary intervention (PCI) has been reported to be effective by numerous registry studies. However, conflicting findings were observed in observational studies (Obs.) and randomised controlled trials (RCTs). OBJECTIVE The purpose of this meta-analysis was to assess the impact of IABP on in-hospital deaths, major adverse cardiovascular events (MACCE), access-site complications and stroke in high-risk PCI cases from Obs. and RCTs published from 1st January, 1990 to 31st March, 2012 and indexed in PubMed. METHODS AND RESULTS We retrieved 1125 studies from the database; 11 studies compared the effects of IABP support, i.e., prophylactic administration (P-IABP) vs. no support (No-IABP), in high-risk patients undergoing PCI. These studies were included in the meta-analysis. We then calculated risk ratios (RRs) and risk differences (RDs) between the two groups of patients (P-IABP vs. No-IABP). We did not observe significant in-hospital mortality, MACCE, access-site complications or stroke differences in the RRs and RDs of the two groups. CONCLUSIONS The results suggest that PCI plus P-IABP support does not result in reduced in-hospital mortality or MACCE nor in significant higher access-site complications or stroke incidence compared with PCI alone in patients at high risk for peri-procedural PCI complications.

Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis

AIM To assess the impact of percutaneous cardiac support in cardiogenic shock (CS) complicating acute myocardial infarction (AMI), treated with percutaneous coronary intervention. METHODS We selected all of the studies published from January 1(st), 1997 to May 15(st), 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization: (1) intra-aortic balloon pump (IABP) vs Medical therapy; (2) percutaneous left ventricular assist devices (PLVADs) vs IABP; (3) complete extracorporeal life support with extracorporeal membrane oxygenation (ECMO) plus IABP vs IABP alone; and (4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 mo of follow-up. RESULTS One thousand two hundred and seventy-two studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was: (1) significantly higher with IABP support vs medical therapy (RR = +15%, P = 0.0002); (2) was higher, although not significantly, with PLVADs compared to IABP (RR = +14%, P = 0.21); and (3) significantly lower in patients treated with ECMO plus IABP vs IABP (RR = -44%, P = 0.0008) or ECMO (RR = -20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP. CONCLUSION Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.

Collateral flow prevents unintentional myocardial ischemia during antegrade cardioplegia in patients undergoing coronary artery bypass grafting

OBJECTIVE We evaluated, in the prevention of perioperative unintentional myocardial ischemia, the role of coronary collateral flow in patients with left anterior descending coronary artery stenosis or occlusion who underwent elective coronary artery bypass grafting. METHODS Coronary lesions and collaterals were assessed by coronary angiography in 21 patients. Anteroseptal myocardial viability was evaluated by dobutamine echocardiography. Antegrade perfusion of cardioplegic solution was assessed by myocardial contrast echocardiography. Time-intensity curves were generated from the anteroseptal region. Twelve parameters were measured and averaged in the following four groups of patients: those with stenosis of the left anterior descending artery and poor collaterals; those with stenosis of the left anterior descending artery and good collaterals; those with occlusion of the left anterior descending artery and good collaterals; and those with occlusion of the left anterior descending artery and poor collaterals. RESULTS Time-intensity curves were significantly different in patients with stenosis versus occlusion of the left anterior descending artery (p < 0.005); multiple comparisons with Bonferronis correction showed that this difference was mainly a result of the impact of collateral circulation (p < 0.01). However, the role of collaterals was nonsignificant within the groups with stenosis and occlusion of the left anterior descending artery. Patients with occlusion of the left anterior descending artery and good collaterals had perfusion parameters similar to those of patients with stenosis of the left anterior descending artery (p = not significant), except for the ascending slope and time to peak values (p < 0.05 and p < 0.01, respectively), which reflected a higher flow resistance in the collateral circulation. Regional systolic function after coronary artery bypass grafting was depressed in patients with poor collaterals and poor perfusion of cardioplegic solution, as compared with findings in other subgroups. CONCLUSIONS Incomplete myocardial protection may impair the early recovery of function after coronary artery bypass grafting.

Spontaneous Left Atrial Echocardiographic Contrast in Mitral Stenosis: Early Disappearance After Valve Replacement

We describe a patient with mitral stenosis and severely enlarged left atrium. Transthoracic echocardiography showed a false image of intraatrial thrombus, whereas transesophageal echocardiography showed massive spontaneous left atrial contrast. Intraoperative transesophageal echocardiography was performed. During cardioplegic arrest the contrast was enhanced, but it gradually and completely cleared 15 minutes after cardiopulmonary by-pass arrest. Transesophageal echocardiography is a useful technique for the study of intraatrial masses and may bring a new dimension to tissue characterization studies.

Trial sequential analysis: the role of the number needed-to-treat in evaluating the clinical relevance of relative risk reduction values in the intra-aortic balloon pump support.

evaluating the clinical relevance of relative risk reduction values in the intra-aortic balloon pump support Flavia Chiarotti , Maria Cristina Acconcia , Domenico Sergi , Francesco Romeo , Quintilio Caretta d,⁎ a Department of Cell Biology and Neuroscience, Italian National Institute of Health, Rome, Italy b Department of Cardiovascular Disease, University of Rome, La Sapienza, Rome, Italy c Department of Cardiovascular Disease, University of Rome, Tor Vergata, Rome, Italy d Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy