Faculty Bibliography

OBJECTIVE: To determine both the etiology of and outcomes associated with access site hematoma requiring transfusion (HRT) in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: Access site hematoma in the setting of PCI is the most frequent periprocedural complication (2-12%). Antiplatelet and antithrombin therapy is designed to lower the incidence of adverse ischemic events while maintaining an acceptable rate of hemorrhagic complications. METHODS: This was a prospective, multi-center, cohort study of consecutive patients undergoing PCI during 3 NHLBI Dynamic Registry recruitment waves (1997-2002). The primary endpoints included the incidence of HRT, in-hospital death, and death at 1-year. RESULTS: The incidence of HRT was 1.8% and femoral access was common. Older age, lower BMI, female sex, concomitant renal, cerebrovascular, peripheral vascular, and pulmonary disease were significantly associated with HRT. Glycoprotein IIb/IIIa inhibitors, thrombolytic therapy, and postprocedure heparin were more commonly used in HRT patients, but there was no difference in thienopiridiene use. Attempted lesions in patients developing HRT were more often calcified, thrombotic, located in an ostial location, or class B2 or C. In-hospital mortality and 1-year death rate was 9 and 4.5 times higher in HRT patients respectively. Following adjustment, HRT remained independently associated with in-hospital mortality (OR 3.59, 95% CI 1.66-7.77) and 1-year death (hazard ratio [HR] 1.65, 95% CI 1.01-2.70, P = 0.048). Independent predictors of HRT included age, female sex, IIb/IIIa inhibitors, thrombolytic agents, and concomitant conditions. CONCLUSIONS: Access site complications, especially HRT, remain a very important predictor of adverse procedural success and patient outcome

BACKGROUND: Ultrasound evaluation of the abdominal aorta and its branches is usually performed transabdominally. Not infrequently, the image quality is suboptimal. Recently, an intracardiac echocardiography probe has become commercially available. These probes are usually inserted intravenously and advanced to the right heart for diagnostic and monitoring purposes during procedures such as atrial septal defect closure and pulmonary vein isolation. Because of the close anatomic relation between the abdominal aorta and the inferior vena cava, we hypothesized that these probes would be useful in the evaluation of the abdominal aorta and the renal arteries. METHODS: Sixteen patients with normal renal function and no history of hypertension who were undergoing a pulmonary vein isolation procedure or atrial septal defect closure were studied. In each patient, the intracardiac echocardiography probe was inserted in the femoral vein and advanced to the right atrium for the evaluation of the left atrium and the pulmonary veins during the procedure. At the end of the therapeutic procedure, the probe was withdrawn into the inferior vena cava for the evaluation of the aorta and renal arteries. RESULTS: High-resolution images of the abdominal aorta from the diaphragm to its bifurcation were easily obtained in all patients. These images allowed for the evaluation of arterial size, shape, and blood flow. Both renal arteries were easily visualized in each patient. With the probe in the inferior vena cava, both renal arteries were parallel to the imaging plane and, therefore, accurate measurement of renal blood flow velocity and individual renal blood flow were measured

A patent foramen ovale (PFO) can act as a conduit between the venous and arterial circulations, allowing right-to-left shunting and bypass of the pulmonary circulation. Brain abscess may develop as a result of paradoxical embolism of organisms through a PFO. In this small series, we report on the closure of PFO for the prevention of recurrent brain abscess. Only prospective, randomized trials comparing PFO closure to conservative therapy could provide a definitive answer as to the optimal strategy for preventing recurrent cerebral abscess

In patients with cardiogenic shock (CS) complicating acute myocardial infarction, echocardiographic and angiographic findings are used to aid diagnosis, determine prognosis, and guide management. The purpose of this analysis from the Should we emergently revascularize Occluded Coronary arteries for Cardiogenic ShocK (SHOCK) trial is to identify relations between the angiographic and echocardiographic features of patients with CS. Such an analysis of the correlations between echocardiographic and angiographic findings in patients with CS may provide insights into the etiology and treatment of CS. In 302 randomized patients, an echocardiogram and an angiogram before revascularization were available in 127 patients. Although the median ejection fraction derived by echocardiography and left ventricular angiography was identical (30%), the positive correlation was weak (R2 = 0.209, p = 0.019). Patients with a larger number of diseased vessels had worse mitral regurgitation (MR) by echocardiography (p = 0.005). There was a significant but weak association between left ventricular angiographic MR grade and echocardiographic MR severity (R2 = 0.162, p = 0.015), but there was no association between culprit vessel and degree of MR. In conclusion, worse coronary artery disease is associated with more severe MR. Echocardiography and angiography are valuable and result in similar estimated ejection fractions in a large cohort, but there is wide variation between the techniques in patients

BACKGROUND: In the SHOCK trial, the group of patients aged >or=75 years did not appear to derive the mortality benefit from early revascularization (ERV) versus initial medical stabilization (IMS) that was seen in patients aged <75 years. We sought to determine the reason for this finding by examining the baseline characteristics and outcomes of the 2 treatment groups by age. METHODS: Patients with cardiogenic shock (CS) secondary to left ventricular (LV) failure were randomized to ERV within 6 hours or to a period of IMS. We compared the characteristics by treatment group of patients aged >or=75 years and of their younger counterparts. RESULTS: Of the 56 enrolled patients aged >or=75 years, those assigned to ERV had lower LV ejection fraction at baseline than IMS-assigned patients (27.5% +/- 12.7% vs 35.6% +/- 11.6%, P = .051). In the elderly ERV and IMS groups, 54.2% and 31.3%, respectively, were women ( P = .105) and 62.5% and 40.6%, respectively, had an anterior infarction (P = .177). The 30-day mortality rate in the ERV group was 75.0% in patients aged >or=75 years and 41.4% in those aged <75 years. In the IMS group, 30-day mortality was 53.1% for those aged >or=75 years, similar to the 56.8% for patients aged <75 years. CONCLUSIONS: Overall, the elderly randomized to ERV did not have better survival than elderly IMS patients. Despite the strong association of age and death post-CS, elderly patients assigned to IMS had a 30-day mortality rate similar to that of IMS patients aged <75 years, suggesting that this was a lower-risk group with more favorable baseline characteristics. The lack of apparent benefit from ERV in elderly patients in the SHOCK trial may thus be due to differences in important baseline characteristics, specifically LV function, and play of chance arising from the small sample size. Therefore, the SHOCK trial overall finding of a 12-month survival benefit for ERV should be viewed as applicable to all patients, including those >or=75 years of age, with acute myocardial infarction complicated by CS

BACKGROUND: Percutaneous coronary rotational atherectomy (PCRA) is a potent stimulus of platelet activation and aggregation in vivo. For this reason, many patients undergoing PCRA are treated with platelet glycoprotein (GP) IIb/IIIa inhibitors. However, there is limited data regarding the ability of GP IIb/IIIa inhibitors to reduce ischemic complications of PCRA and no data regarding their effect on long-term survival. METHODS: Data on 1138 consecutive patients undergoing PCRA in 5 hospitals in 1998-1999 were pooled and analyzed. Long-term survival was available for all 530 patients treated in 3 of the hospitals. RESULTS AND CONCLUSIONS: GP IIb/IIIa inhibitors were administered to 315 of 1138 (28%) PCRA patients. There was no difference in age, gender or race among patients treated with and without GP IIb/IIIa antagonists. The prevalence of hypertension, diabetes, renal insufficiency and peripheral vascular disease did not differ between groups. Unstable angina was more common among patients treated with GP IIb/IIIa inhibitors (45% vs. 38%, P = 0.036) Patients treated with GP IIb/IIIa inhibitors had lower ejection fractions (50% vs. 55%, P < 0.001) and more 3-vessel coronary disease (24% vs. 16%, P = 0.002). Angiographic success was over 99% in both groups (P = NS). The frequency of major adverse cardiovascular events (MACE) was slightly greater in GP IIb/IIIa inhibitor treated patients (3.8% vs. 2.2%, P = 0.126). At a mean follow-up of 3 years, mortality was 13.3% in the GP IIb/IIIa treated patients and 12% in the untreated patients (P = 0.224). On Cox proportional hazards analysis, treatment with a GP IIb/IIIa inhibitor was not significantly associated with increased survival (Hazard Ratio, 0.81, 95% Confidence Interval, 0.631-1.039, P = 0.098). These data do not indicate a significant association between GP IIb/IIIa inhibitor treatment during PCRA and MACE or survival. CONDENSED ABSTRACT: There is limited data regarding the ability of GP IIb/IIIa inhibitors to reduce ischemic complications of percutaneous coronary rotational atherectomy (PCRA) and no data regarding their effect on long-term survival. These data do not indicate a significant association between GP IIb/IIIa inhibitor treatment during PCRA and MACE or survival

OBJECTIVES: We sought to analyze clinical, angiographic, and outcome correlates of hemodynamic parameters in cardiogenic shock. BACKGROUND: The significance of right heart catheterization in critically ill patients is controversial, despite the prognostic importance of the derived measurements. Cardiac power is a novel hemodynamic parameter. METHODS: A total of 541 patients with cardiogenic shock who were enrolled in the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial registry were included. Cardiac power output (CPO) (W) was calculated as mean arterial pressure x cardiac output/451. RESULTS: On univariate analysis, CPO, cardiac power index (CPI), cardiac output, cardiac index, stroke volume, left ventricular work, left ventricular work index, stroke work, mean arterial pressure, systolic and diastolic blood pressure (all p < 0.001), coronary perfusion pressure (p = 0.002), ejection fraction (p = 0.013), and pulmonary artery systolic pressure (p = 0.047) were associated with in-hospital mortality. In separate multivariate analyses, CPO (odds ratio per 0.20 W: 0.60 [95% confidence interval, 0.44 to 0.83], p = 0.002; n = 181) and CPI (odds ratio per 0.10 W/m(2): 0.65 [95% confidence interval, 0.48 to 0.87], p = 0.004; n = 178) remained the strongest independent hemodynamic correlates of in-hospital mortality after adjusting for age and history of hypertension. There was an inverse correlation between CPI and age (correlation coefficient: -0.334, p < 0.001). Women had a lower CPI than men (0.29 +/- 0.11 vs. 0.35 +/- 0.15 W/m(2), p = 0.005). After adjusting for age, female gender remained associated with CPI (p = 0.032). CONCLUSIONS: Cardiac power is the strongest independent hemodynamic correlate of in-hospital mortality in patients with cardiogenic shock. Increasing age and female gender are independently associated with lower cardiac power

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the United States and other industrialized countries. In the undeveloped world a similar epidemic is brewing. A new pathophysiologic paradigm has emerged, which assigns the mediators of inflammation a much larger role in the disease process. This paradigm has helped explain the unpredictable nature of many adverse consequences of CAD. The long latent phase of the disease, and often sudden initial presentation, make efforts at early detection extremely important. Considerable work has been devoted to identify, as well as influence, predisposing risk factors for developing arteriosclerosis. Novel markers of inflammation, like C-reactive protein, have been identified and compared to traditional risk factors. In addition, new imaging modalities introduce the possibility of screening for subclinical disease. Electron beam and multidetector computed tomography (CT) scanners, as well as other techniques, are emerging as powerful tools to detect early disease presence and allow intervention to take place before major clinical events occur. Advances in our understanding of the pathophysiology of CAD, and our ability to image the stages of silent disease will go hand in hand to revolutionize our approach to prevention and treatment of this deadly malady