Hospital Chronicles (E-Journal)
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New Antithrombotic Drugs in Acute Coronary Syndromes: the Role of Fondaparinux and Bivalirudin in Reducing Major Hemorrhages and Mortality
Get PDFTwo newer antithrombins have recently been tested for efficacy and safety in the treatment of acute coronary syndromes (ACS), an indirect antithrombin, fondaparinux, a synthetic pentasacharide with anti-Xa properties, and a direct thrombin inhibitor, bivalirudin, having an anticoagulant effect against both free and clot-bound thrombin. Both these newer antithrombotic agents are recommended in current guidelines as anthithrombotic therapies in ACS patients with their main advantage being increased safety due to reduced bleeding events
Cryptogenic Stroke and Migraine Headache: The Clinical Cardiologist???s View
Get PDFCryptogenic stroke and migraine headache are disorders which most commonly affect persons younger than 55 years of age. In recent years these disorders have been found to have a strong association with inter-atrial cardiac defects, such as patent foramen ovale and atrial septal defect, and support the pathophysiological mechanism of paradoxical embolism with a right-to-left shunt. With the evolution of technology, magnetic resonance imaging has more clearly defined cryptogenic stroke, and percutaneous cardiac interventional devices have offered a simplified approach to closure of inter-atrial cardiac defects. Nevertheless, the evidence-based data of which sub-populations of patients with cryptogenic stroke or migraine headache will benefit from closure of inter-atrial cardiac defects is just being defined. This review offers a clinical cardiologist’s viewpoint of these developments
Primary Prevention of Sudden Cardiac Death: Implications of Recent Trials
Get PDFBased on the results of randomized multicenter studies, such as the MADIT I, MADIT II, DINAMIT, and SCD-HeFT and DEFINITE trials, patients can be identified who are at high risk for sudden cardiac death (SCD) who demonstrate a reduction in arrhythmic mortality and total mortality with the implantation of an implantable cardioverter defibrillator (ICD). These are patients with coronary artery disease, impaired left ventricular function, spontaneous nonsustained ventricular tachycardia and inducible ventricular tachycardia not suppressed by procainamide. Also patients with coronary artery disease and left ventricular ejection fraction < 30% benefit from ICD placement. Based on the SCD-HeFT results, patients with ischemic or nonischemic cardiomyopathy and class II or III congestive heart failure also benefit from the ICD. At the same time, based on the results of the DINAMIT study, it has become apparent that the ICD does not play a role in patients within 45 days of myocardial infarction. The implications of these trials are further analyzed in this overview
Catheter Ablation of Atrial Fibrillation
Get PDFCatheter ablation of atrial fibrillation (AF) has become a viable therapeutic alternative in symptomatic patients resistant to antiarrhythmic drugs. Since the first report of catheter ablation a decade ago, several techniques have evolved. These techniques reflect principal mechanisms of AF. Besides segmental electrical isolation, circumferential ablation around the pulmonary venous ostia with a support of the 3D electroanatomical mapping system appears to be the most frequently used techniques. Some authors use various combinations of these techniques including guidance with intracardiac echocardiography (ICE). Most recently, ablation within areas of fractionated electrograms during AF has been proposed. The aim of this review is to summarize briefly current techniques, their efficacy and safety
Transcatheter Closure of Secundum Atrial Septal Defect Using the Amplatzer Device: Single Center Experience in 140 Patients
Get PDFBACKGROUND: Transcatheter closure of secundum atrial septal defect (ASD) is nowadays widely practiced and has replaced surgical ASD closure in many centers. Improvements in design have made the closure devices retrievable, and reduction in the size of the introduction systems allows interventional treatment even in young patients. In this paper we present our experience with the Amplatzer septal occluder device in patients with ASD. PATIENTS AND METHODS: Between October 2002 and February 2006, 206 consecutive patients with a significant ASD, demonstrated by initial transthoracic echocardiography (TTE), were considered for transcatheter closure with the Amplatzer septal occluder. A total of 156 patients underwent cardiac catheterization, and 140 patients had successful transcatheter ASD closure. Routine examination before catheterization included a standard ECG, a chest x ray, blood tests and TTE. The initial TTE showed the location of the ASD, its septal rim, and its diameter and also helped to measure the length of the interatrial septum in the four-chamber view. These measurements were used to assess the feasibility of transcatheter closure with the Amplatzer device. The “stretched” diameter of the ASD, determined by a balloon sizing catheter, was used to select the diameter of the waist of the device. The size of the selected device was 1 to 2 mm larger than the stretched diameter of the defect. Transesophageal echocardiography was used to monitor the implantation procedure. RESULTS: The Amplatzer device was finally employed in 140 patients for percutaneous closure of ASD. The age of patients ranged between 5.3 and 70 years, median 21.9 years. Procedure time ranged between 25 and 240 minutes, median 60 minutes; fluoroscopy time ranged between 3.5 and 45 minutes, median 12 minutes. The size of the selected device ranged between 6-40 mm. Two devices were implanted in two patients. Serious procedure related complications (embolization and perforation of the left atrial wall) occurred in two cases. At follow up (10 days to 3.4 years, median 2.3 years) complete closure was documented in 97% of this patient group. Unrecognized during implantation, but detected after release, small additional defect with trivial residual shunt was documented in 4 patients. A young critically ill patient, cyanotic due to right-to-left shunt, with complex congenital heart disease developed a brain abscess three months after implantation. CONCLUSION: Percutaneous ASD closure with use of the Amplatzer device in this cohort of 140 patients was highly successful with a low complication rate
Why and How We Should Avoid Right Ventricular Apical Pacing?
Get PDFA large body of evidence has emerged recently about the harmful effects of chronic right ventricular (RV) apical pacing on left ventricular (LV) function leading to an increase in morbidity and mortality. Right ventricular apical pacing is unphysiologic because it produces aberrant LV depolarization, and in turn mechanical LV dyssynchrony with resultant long-term unfavorable hemodynamic and structural changes. Although the data about RV pacing-induced LV dysfunction outlined in this discussion are persuasive, its clinical applicability in pacemaker practice remains challenging. The ongoing transition to new pacing sites will succeed only with major technologic improvements in lead implantation. Meanwhile, pacing algorithms minimizing right ventricular pacing might be preferable at least in patients with sick sinus syndrome or non-permanent atrioventricular block
Home Monitoring for Implantable Devices: New Technology & New Service
Get PDFThe use and need for follow-up of cardiac electronic implantable devices, such as pacemakers and implantable defibrillators, is constantly increasing, and constitutes an ever-growing burden and cost in clinical practice and the health system in general. Telemedicine or remote, wireless home monitoring (HM) has recently come to aid in this situation and reliably retrieve information on the patient`s and device`s status and transmit it to the implanting center and physician. It thus offers considerable convenience and assurance to both patient and physician. To date this technology of remote monitoring allows continuous and episode related arrhythmia monitoring as well as continuous monitoring of the status of the implanted system (battery status, lead impedance). Preliminary data from ongoing large multicenter studies are promising and relate to the diagnostic power of telemetrically transmitted data, necessity for patient follow up, the influence of HM on the optimisation of device and medical therapy, and the impact of HM on cost- effectiveness in device therapy
Methods of Differentiation of Inferior, or Other Myocardial Wall Defects From Artifacts in Myocardial Scintigraphy: The Role of Prone Positioning and/or Other Techniques
Get PDFStress radionuclide myocardial perfusion scintigraphy (MPS) with the use of single photon emission computed tomography (SPECT) is a widely established method for the detection of coronary artery disease, patient management and patient risk stratification, as well as evaluation of revascularization results. MPS SPECT is traditionally being performed with patients in the supine position. This practice is, however, associated with various soft tissue attenuation artifacts, resulting in reduced test specificity. Various methods have been investigated to deal with this problem including the inspection of planar projection images, the integration of wall motion and wall thickening information from gated MPS, the application of transmission attenuation maps from radionuclide sources and the MPS SPECT with the patient in prone position. Most of the above methods suffer from several limitations. However, the addition of prone acquisition to traditional supine MPS SPECT has been proven to be an easy and efficient way to reduce attenuation artifacts (concerning mainly the inferior wall) leading to a significant improvement in the specificity of this imaging technique
Rheumatoid Cachexia: causes, significance and possible interventions
Get PDFRheumatoid arthritis is a chronic autoimmune disease characterised by joint pain and stiffness but also systemic mutli-organ involvement. Several features are due to excessive production of inflammatory cytokines, particularly tumour necrosis factor alpha, interleukin-1 and interleukin-6. These are implicated in both local synovial inflammation, which causes joint destruction, but also systemic inflammation, which can cause loss of body cell mass, amongst other phenomena. Body cell mass breakdown in rheumatoid arthritis leads to the classical, but largely ignored, metabolic abnormality known as rheumatoid cachexia. Cachexia is a very strong predictor of adverse functional outcome and death in many disease states. In this review we highlight the mechanisms linked with rheumatoid cachexia and discuss possible interventions that may limit this in patients with rheumatoid arthritis
Prevotella Buccae Bacteremia and Febrile Neutropenia: Report of one Case
Get PDFAn increasing number of anaerobic bacteremias of oral origin have been described during the recent years as a cause of fever in neutropenic cancer patients. In this paper, we describe a case of Prevotella buccae bacteremia, the first one to our knowledge, emphasizing thus the importance of considering the oral commensals when selecting antimicrobial regimens