Larger Ischemic Area Research Articles

Near Complete Biliopancreatic Segment Necrosis: A Rare and Unknown Entity Observed After Roux-en-Y Gastric Bypass-A Case Report.

Roux-en-Y gastric bypass is one of the common bariatric surgery procedures performed worldwide. Necrosis of the biliopancreatic or Roux limbs in the late period after RYGB is a rarely observed condition, the most common causes of which are postoperative adhesion, inflammatory entities, volvulus, intussusception, and internal herniations. The goal of surgical treatment is the removal of the necrotic segment and the reconstruction of biliopancreatic or gastric drainage. Here, we present a rare case in which a patient developed complete necrosis of the third and fourth segments of the duodenum and proximal jejunal limb in the postoperative seventh month after undergoing Roux-en-Y gastric bypass surgery. Necrosis occurring after RYGB surgery often affects the Roux limb, though necrosis of the biliopancreatic limb is extremely rare. The goal of surgery is to remove the necrotic segment and reconstruct the drainage. An area of ischemia is often observed in the jejunum, while a large ischemic area was noted in the present case that encompassed the third and fourth parts of the duodenum. Although in general necrosis of the Roux limb occurs due to volvulus, intussusception, or internal herniation following RYGB surgery, it must be taken into account that necrosis of the jejunal, duodenal, or complete biliopancreatic segment may occur in cases in which the underlying etiology cannot be exactly revealed.

Endovascular Thrombectomy for Large Ischemic Strokes: A Living Systematic Review and Meta-Analysis of Randomized Trials.

New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only. We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only. Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization-A Workflow Focusing on Non-Invasive Cardiac Imaging.

Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician's discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions.

Injuria cerebral aguda causada por oclusión de gran vaso por COVID–19

En la pandemia de la enfermedad por el coronavirus 2019 (COVID-19) causada por el virus SARS-CoV2, la mayoría de los pacientes presentan síntomas generales y respiratorios, algunos cuadros atípicos gastrointestinales, cardiovasculares, dermatológicos o neurológicos. Se reporta el caso de un paciente varón de 40 años, sin ningún antecedente epidemiológico importante, diagnosticado de COVID 19 por prueba rápida inmunológica, quien presenta un accidente cerebro vascular isquémico súbito. En el estudio tomográfco cerebral sin contraste se evidenció un área extensa isquémica, en el hemisferio cerebral izquierdo en territorio de la arteria cerebral media, acompañado de edema. En los pacientes con COVID-19, infectados por coronavirus SARS-CoV2, debe tenerse en cuenta la posibilidad de que el paciente presente accidente cerebrovascular (ACV), para permitir un manejo adecuado y oportuno.

Longitudinal optical coherence tomography imaging of tissue repair and microvasculature regeneration and function after targeted cerebral ischemia.

.Significance: Understanding how the brain recovers from cerebral tissue and vascular damage after an ischemic event can help develop new therapeutic strategies for the treatment of stroke.Aim: We investigated cerebral tissue repair and microvasculature regeneration and function after a targeted ischemic stroke.Approach: Following photothrombosis occlusion of microvasculature, chronic optical coherence tomography (OCT)-based angiography was used to track ischemic tissue repair and microvasculature regeneration at three different cortical depths and up to 28 days in awake animals. Capillary network orientation analysis was performed to study the structural pattern of newly formed microvasculature. Based on the time-resolved OCT-angiography, we also investigated capillary stalling, which is likely related to ischemic stroke-induced inflammation.Results: Deeper cerebral tissue was found to have a larger ischemic area than shallower regions at any time point during the course of poststroke recovery, which suggests that cerebral tissue located deep in the cortex is more vulnerable. Regenerated microvasculature had a highly organized pattern at all cortical depths with a higher degree of structural reorganization in deeper regions. Additionally, capillary stalling event analysis revealed that cerebral ischemia augmented stalling events considerably.Conclusion: Longitudinal OCT angiography reveals that regenerated capillary network has a highly directional pattern and an increased density and incidence of capillary stalling event.

Platelet recovery correlates parenchymal volume recovery after liver resection.

Platelet count seems to assess liver function and predict liver regeneration, but factors associated with liver regeneration remain unclear. This study analyzed the relationship between platelet recovery and postresection liver regeneration. Data from 343 candidates from 1245 consecutive patients with liver resection of more than Couinaud's segments were analyzed. Patients were divided into a low-platelet-recovery rate (LPRR) group (lowest 25%) or a control group on the basis of the platelet recovery rate on postoperative day (POD)7. Data were matched before analysis to adjust for operation scale. Trends in liver functional recovery were assessed, and liver volume recovery and remnant ischemic area was calculated using computed tomography volumetry. Factors predicting liver regeneration were analyzed. In 78 matched-pair patients, the all-complications rate (42.3% vs. 26.9%, P = 0.002) and infectious complications rate (21.8% vs. 9.0%, P = 0.027) were significantly higher in the LPRR group than in controls. Trends in liver functional recovery did not differ significantly, whereas significant differences remained for platelet recovery. Parenchyma volume recovery was delayed in the LPRR group from POD7 (84.5% vs. 78.1, P < 0.01) to POD30 (92.5% vs. 85.6, P < 0.01). Platelet recovery rate on POD7 correlated negatively with ischemic liver volume as evaluated on POD2 by computed tomography (r = 0.691). Postoperative ischemic volume on POD2 (5.41 [1.98-11.21], P < 0.001), infectious complications (3.48 [1.44-7.37], P < 0.001), and multiple resection (1.67 [1.10-4.11], P = 0.011) predicted delayed platelet recovery rate on multivariate analysis. Platelet recovery correlated with liver volume recovery and occurrence of complications. Large ischemic area might negatively impact regeneration after liver resection.

Chronic total occlusion percutaneous coronary intervention in Latin America.

To report clinical, angiographic characteristics, outcomes, and predictors of unsuccessful procedures in patients who underwent chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in Latin America. CTO PCI has been increasingly performed worldwide, but there is a lack of information in this region. An international multicenter registry was developed to collect data on CTO PCI performed in centers in Latin America. Patient, angiographic, procedural and outcome data were evaluated. Predictors of unsuccessful procedures were assessed by multivariable analysis. We have included data related to 1,040 CTO PCIs performed in seven countries in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, and Puerto Rico). The mean age was 64 ± 10 years, and CTO PCI was performed mainly for angina control (81%) or treatment of a large ischemic area (30%). Overall technical success rate was 82.5%, and it was achieved with antegrade wire escalation in 81%, antegrade dissection/re-entry in 8% and with retrograde techniques in 11% of the successful procedures. Multivariable analysis identified moderate/severe calcification, a blunt proximal cap and a previous attempt as independent predictors of unsuccessful procedures. In-hospital major adverse cardiovascular events (MACE) occurred in 3.1% of the cases, death in 1% and cardiac tamponade in 0.9% CONCLUSIONS: CTO PCI in Latin America has been performed mainly for ischemia relief. Procedures were associated with a success rate above 80% and low incidence of MACE. Predictors of unsuccessful procedures were similar to those previously reported in the literature.

Changing Ischemic Lesion Patterns and Hemodynamics of the Posterior Cerebral Artery in Moyamoya Disease

The aim of this study was to determine how hemodynamics of the posterior cerebral artery (PCA) are associated with cerebral ischemic lesions in moyamoya disease (MMD). Thirty-six patients with ischemic MMD (Suzuki grade IV-V) were retrospectively analyzed. Hemodynamic parameters of the PCA were measured by transcranial color-coded sonography. We classified the range of ischemic lesions into 3 grades and perfusion levels into 3 grades according to computed tomography (CT) results. PCA steno-occlusion and leptomeningeal collaterals were confirmed by digital subtraction angiography. Ultrasonographic parameters in the PCA were compared with these radiographic findings. The velocity in the involved PCA (mean flow velocity [MFV] median, 42.00 [range, 34.50-58.00] cm/s) was significantly lower than that in the normal PCA (MFV median, 95.00 [range, 76.50-119.50] cm/s) (P < .001). The velocity in the PCA increased significantly as the leptomeningeal collateral stage advanced (MFV stage 1: median, 38.50 [range, 29.75-63.50] cm/s; stage 2: median, 55.00 [range, 44.00-96.00] cm/s; stage 3: median, 94.00 [range, 54.00-118.25] cm/s; stage 4: median, 85.50 [range, 70.50-117.75] cm/s, respectively) (P < .05). Decreased PCA velocities were associated with a larger ischemic area on CT (P ≤ .001). PCA velocity had no correlation with CT perfusion level of the temporal and frontal lobes. PCA velocity had significant correlations with perfusion level in the occipital (P < .001) and parietal lobes (P < .05). Our results suggest ischemic lesion patterns (as demonstrated on CT imaging) are associated with PCA velocity measurements in the advanced stage of MMD. Thus, monitoring PCA velocity in patients with advanced MMD may provide additional information to assist in managing these patients.

Relationship between normalized distributional pattern and functional outcome in patients with acute cardiogenic cerebral embolism.

This study aimed to elucidate spatial characteristics for magnetic resonance imaging (MRI) of cardiogenic cerebral embolism, to determine imaging biomarkers predicting patient outcome and cerebral herniation in cardioembolic stroke. This retrospective study assessed 90 patients with cardiogenic cerebral embolism. All images from MRI were normalized using a voxel-based symptom lesion mapping technique. Patients were categorized into two subgroups based on the outcome and presence of cerebral herniation. Each subgroup was assessed individually. The distribution map of all analyzed patients revealed accumulated ischemic lesions in bilateral middle cerebral artery areas. Ischemic lesions for the poor outcome group accumulated at the corona radiata on the right side and throughout the entire left hemisphere. Receiver operating characteristic (ROC) analysis suggested that a normalized ischemic volume of 62.8 mL allowed optimal differentiation between good and poor outcomes (sensitivity, 0.923; specificity, 0.923; area under the curve (AUC), 0.91) for left-side-dominant infarction. The distribution map for the cerebral herniation group revealed large ischemic areas in the left hemisphere. The analysis of differential involvement map with random permutation analysis showed that left anterior circulation infarcts were associated with midline shift. Receiver operating characteristic analysis revealed that a normalized infarction volume of 192.9 mL was highly predictive of cerebral herniation (sensitivity, 0.929; specificity, 0.750; AUC, 0.895). The medial frontal and occipital lobes, caudate head and basal ganglia were significantly involved in those patients who developed cerebral herniation. Ischemic volume contributed to outcomes and cerebral herniation. Ischemic lesions of the anterior and posterior cerebral arteries and basal ganglia in addition to middle cerebral artery area were identified as differences on MRI images between with and without cerebral herniation patients.

Análise crítica e comentários acerca da craniectomia descompressiva no tratamento da hipertensão intracraniana refratária decorrente de isquemia no território da artéria cerebral média

Introdução: A hipertensão intracraniana refratária secundária ao infarto do território da artéria cerebral média ainda hoje representa uma complexa questão neurocirúrgica. Neste contexto, a craniectomia descompressiva, incluindo suasvariantes, representa uma alternativa envolta em controvérsia. Materiais e métodos: A literatura recente (após 1990) sobre o assunto é revisada, focalizando as principais indicações, diferentes técnicas, timing da cirurgia, complicações e resultados. O total de 19 artigos foram considerados mais relevantes, porémnenhum deles consiste em estudo prospectivo e/ou randomizado. Resultados: A maioria dos artigos, embora longe de um consenso, inclina-se em favor da indicação mais precoce da descompressão baseada em sinais de diminuição do fluxo e aumento da hipertensão intracraniana ou de grande área isquêmica nosexames de imagem com detecção precoce do infarto, enfatizando ainda a importância da avaliação do fluxo sangüíneo regional através do Doppler transcraniano ao longo de toda a evolução do paciente. A maior parte dos estudos também exclui da craniectomia descompressiva aqueles pacientes mais idosos ou com comorbidades graves ou neoplásicas. Conclusão: Apesar de não haver protocolos clínicos de nível I ou II sobre o assunto, cristaliza-se a indicação da craniectomia descompressiva como medida destinada a preservar a vida do paciente.

High Risk of Seizures and Epilepsy after Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke

Background: Decompressive hemicraniectomy (DHC) is a life-saving procedure for treatment of large malignant middle cerebral artery (MCA) strokes. Post-stroke epilepsy is an additional burden for these patients, but its incidence and the risk factors for its development have been poorly investigated. Objective: To report the prevalence and risk factors for post-stroke seizures and post-stroke epilepsy after DHC for treatment of large malignant MCA strokes in a cohort of 36 patients. Methods: In a retrospective cohort study of 36 patients we report the timing and incidence of post-stroke epilepsy. We analyzed if age, sex, vascular risk factors, side of ischemia, reperfusion therapy, stroke etiology, extension of stroke, hemorrhagic transformation, ECASS scores, National Institutes of Health Stroke Scale (NIHSS) scores, or modified Rankin scores were risk factors for seizure or epilepsy after DHC for treatment of large MCA strokes. Results: The mean patient follow-up time was 1,086 days (SD = 1,172). Out of 36 patients, 9 (25.0%) died before being discharged. After 1 year, a total of 11 patients (30.6%) had died, but 22 (61.1%) of them had a modified Rankin score ≤4. Thirteen patients (36.1%) developed seizures within the first week after stroke. Seizures occurred in 22 (61.1%) of 36 patients (95% CI = 45.17–77.03%). Out of 34 patients who survived the acute period, 19 (55.9%) developed epilepsy after MCA infarcts and DHC (95% CI = 39.21–72.59%). In this study, no significant differences were observed between the patients who developed seizures or epilepsy and those who remained free of seizures or epilepsy regarding age, sex, side of stroke, presence of the clinical risk factors studied, hemorrhagic transformation, time of craniectomy, and Rankin score after 1 year of stroke. Conclusion: The incidence of seizures and epilepsy after malignant MCA infarcts submitted to DHC might be very high. Seizure might occur precociously in patients who are not submitted to anticonvulsant prophylaxis. The large stroke volume and the large cortical ischemic area seem to be the main risk factors for seizure or epilepsy development in this subtype of stroke.

ST-depression in right precordial leads with inferior STEMI and occluded right coronary artery: intertwined anatomy and ischemic areas

Right coronary artery (RCA) occlusion in inferior acute myocardial infarction is usually heralded by ST-elevation both in inferior and in right precordial leads. We report the case of a 68-year-old male, who presented marked ST-elevation in inferior leads, mirrored by ST-depression in anterior-septal and lateral leads. Right precordial lead electrocardiogram unexpectedly showed ST-depression V1R–V5R leads. Coronary angiography showed mid-left anterior descending (LAD) coronary near-complete occlusion with distal wrapping LAD. Left circumflex artery was not occluded, while RCA was occluded mid tract. The patient was treated with coronary angioplasty on RCA and LAD. Absence of ST-elevation in right precordial leads may be presumably explained by the presence of a large ischemic area distal to mid-LAD near-occlusive stenosis and of a long-wrapping LAD. Complex coronary anatomy and intertwined ischemic areas may underlie apparently discording electrocardiograms.

Le spasme coronaire lié à la dobutamine chez les patients avec des échocardiographies de stress faussement positives : prévalence et facteurs prédictifs

Background and objectiveDobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram). MethodsThree thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm (“true” false positive DSE). ResultsTwenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm (“true” false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P=0.003); they had more frequently dyslipidemia (79.3% vs 43%; P=0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P=0.05). On multivariate analysis, dyslipidemia (HR=10.7; 95% CI=[2.7–42.1]; P=0.001) and active smoking (HR=6.1; 95% CI=[1.7–21.1]; P=0.004) were found to be independent predictors of spasm-related DSE rather than “true” false positive DSE. ConclusionDSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled “false” positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than “true” false positive DSE.

0027: Dobutamine-related coronary spasm among patients with false positive dobutamine stress echocardiography: prevalence and predictors

Dobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobuta-mine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angio-gram) 3952 patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm (« true » false positive DSE) 29 patients with DSE-related vasospasm (19.4% of positive DSE without known CAD) were compared with 56 patients with no lesions and no spam (« true » false positive DSE). They were more frequently smokers (72.4% vs 37.5%; p=0.003); they had more frequently dyslipidemia (79.3% vs 43%;p=0.001); they also had a larger ischemic area at peak DSE (3.4 vs 2.7 segments; p=0.05). On multivariate analysis, dyslipidemia (HR=10.7; 95% CI= [2.7-42.1]; p=0.001) and active smoking (HR=6.1; 95% CI= [1.7-21.1]; p=0.004) were found to be independant predictors of spam-related DSE rather than « true » false positive DSE. DSE- related coronary spasm is present in a significant proportion of patients with erroneously labelled « false » positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independant predictors of spasm rather than « true » false positive DSE

Reperfusion of Large Ischemic Areas Associated With Central Retinal Vein Occlusion

Reperfusion of Large Ischemic Areas Associated With Central Retinal Vein Occlusion

Intra-aortic balloon pump in intensive cardiac care: A registry in Florence

The Intra-aortic Balloon Pump (IABP) is currently the most commonly used mechanical assist device to improve and support hemodynamics in patients with cardiogenic shock; it is widely used also in high-risk patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) [1–9]. However, the impact of IABP on prognosis is so far controversial [5,10]. We assessed the in-hospital mortality and complications in patients treated with IABP consecutively admitted to our Intensive Cardiac Care Unit (ICCU). From Jan. 1, 2005 to Dec. 31, 2008, 3500 patients were consecutively admitted to our ICCU [11–13]. Among them, 414 (11.8%) underwent IABP during their hospitalization and were prospectively enrolled in our Registry. Large ischemic risk area (LIRA)was defined as “ejection fraction less than 40% together with proximal occlusion of left descending anterior coronary artery associated or not with critical lesions in other coronary arteries”. In these patients IABP was deployed after PCI. Patients were defined as “high risk” as if one ormore of the following criteria were present: ventricular ejection fraction (LVEF)<40%, killip class 3, persistent malignant ventricular arrhythmias, acute mitral regurgitation and severe coronary artery disease (left main stem or three vessel or vein graft disease). Major bleeding.Major bleeding was defined according to Replace 2 [14]: Continuous data (Kolmogorov–Smirnov test ) were expressed as mean±SD, categorical data as frequencies and percentages. All data were analysed by means of Fisher's exact test or Student's t test, when appropriate. Variables resulted significantly different between subgroups were entered as covariates in a backward stepwise logistic regression analysis. A p<0.05 was considered statistical significant (SPSS 13.0 statistical software; SPSS Inc., Chicago, ILL, USA). The mean age of patients in the study was 68.5±11.4 years; 69.6% were men. Hypertension was detectable in 51.4% (n=213), dyslipidemia in 32.1% (n=133) and diabetes mellitus in 22.0% (n=91). About one fourth of patients (24.4%) showed prior myocardial infarction and prior PCI in the 20.5%. Table 1 shows indications for IABP in our series. In the majority of patients (67.1%, n=278) IABP was the only device, while in the remaining (32.9%) it was associated to other devices. The device most frequently associated with IABP was mechanical ventilation (41.7%; invasive: 24.6%; non-invasive 17.1%). The continuous veno-venous renal replacement therapy was used in 13.5% (n=56) of patients. Unfractioned heparin was used in 97.8% of patients. The majority of patients received dual antiplatelet therapy; acetylsalicylic acid (90.6%) and clopidogrel (83.8%). Therapy with glycoprotein IIb IIIa inhibitors was administered in 59.7% of cases. Inotropic agents (epinephrine, norepinephrine, dopamine and dobutamine) were used in 40.6% of patients, all with refractory cardiogenic shock. In our series, complications were 13.8% (57/414 patients) (Table 2). Thirtypatients (outof 57, 52.7.%) showed severebleeding, amongwhich half of patients exhibited unknown bleeding site while bleeding at the insertion site occurred in 12 patients. The incidence of IABP-related complications did not differ betweenmales and females (10.6%@versus 13.9% p=0.398). Patients who developed IABP-related complications showed a higher median duration of the device (48 h; 25–75th percentile 24–72 hversus 36 h;25–75thpercentile 24–48 h;p=0.007). In our population, 82 patients died (82/414:19.8%). Among patients who died, IABP was implanted because of: cardiogenic shock in 59 patients (72%), cardiac arrest in 8 patients (9.8%), periprocedural complications of PCI in 5 patients (6.1%), mechanical complication of acute myocardial infarction in 4 patients (4.9%), large ischemic risk area in 3 patients (3.6%), acute pulmonary edema in 2 patients (2.4%) and bridge to CABG in 1 patient (1.2%). Among the 47 patientswhodeveloped IABP-related complications 22 died; two deaths were due to IABP (intestinal ischemia in 1 patients and

Local Gene Transfer and Expression Following Intramuscular Administration of FGF-1 Plasmid DNA in Patients With Critical Limb Ischemia

NV1FGF is an expression plasmid encoding sp.FGF-1(21-154) currently under investigation for therapeutic angiogenesis in clinical trials. NV1FGF plasmid distribution and transgene expression following intramuscular (IM) injection in patients is unknown. The study involved six patients with chronic critical limb ischemia (CLI) planned to undergo amputation. A total dose of 0.5, 2, or 4 mg NV1FGF was administered as eight IM injections (0.006, 0.25, or 0.5 mg per injection) 3-5 days before amputation. Injected sites (30 cm(3)) were divided into equally sized smaller pieces to assess spatial distribution of NV1FGF sequences (PCR), NV1FGF mRNA (reverse transcriptase-PCR), and fibroblast growth factor-1 (FGF-1)-expressing cells (immunohistochemistry). Data indicated gene expression at all doses. The distribution area was within 5-12 cm for NV1FGF sequences containing the expression cassette, up to 5 cm for NV1FGF mRNA, and up to 3 cm for FGF-1-expressing myofibers. All FGF receptors were detected indicating robust potential for bioactivity after NV1FGF gene transfer. Circulating levels of NV1FGF sequences were shown to decrease within days after injection. Data support demonstration of plasmid-mediated gene transfer and expression in muscles from patients with CLI. FGF-1 expression was shown to be limited to injection sites, which supports the concept of multiple-site injection for therapeutic use.

Asistencia mecánica ventricular de corta duración (shock cardiogénico)

AbstractShort-term ventricular assist devices are used in patients suffering a potentially reversible ventricular dysfunction. Any cause of cardiogenic shock can be a potential indication for mechanical support, although higher benefits are to be expected in potentially reversible causes such as acute myocarditis, drug overdose, hypothermia, and ventricular tachycardia or fibrillation. the main indications for ventricular assist support are: 1) severe and reversible ventricular failure therefore assuring temporary circulatory support until recovery or revascularization; 2) patients with large ischemic areas at risk, providing temporary circulatory support during high-risk percutaneous or surgical revascularization, and 3) bridging therapy towards a permanent assist device or heart transplantation.

Infrared imaging contribution for intestinal ischemia detection in wound healing

To study thermal variations obtained through infrared image in rats, and to evaluate the relationship between intestinal ischemic time and histopathological findings. Thirty Wistar rats were operated after distribution in 5 groups with different times of ischemia. Thermograms were obtained by using a infrared camera. The surgical technique has been standardized for all groups: abdominal cavity opening by a 5 cm length incision in the midline, abdominal wall plans section and cavity exposure, and exteriorization of the intestine. In group I (control), it was proceeded only laparotomy without superior mesenteric artery ligature. After first thermogram done, incision was closed with continuing suture. In each rat in groups II, III, IV and V, the superior mesenteric artery was located at its origin on abdominal aorta, dissected and occluded with a vascular microclamp, subjecting the intestine to ischemia in variable times. Rats submitted to a 30 minutes ischemia presented reactive hyperemia, thermal differential of 1.8 degrees C and normal pathological examination. The 1 hour ischemia produced reactive hyperemia with ischemic areas, thermal differential of 1.0 degrees C and injuries at villosities' tips. However, the 90 minutes ischemia had not shown reactive hyperemia with large ischemic areas, thermal differential of -1.0 degrees C and injury in the upper third of the villosities. The 2 hours ischemia demonstrated a severe ischemia, thermal differential of -2.0 degrees C and injury throughout the all villosities' extension. It has been possible studying thermal variations through infrared image in rats, showing correlation between thermal response in thermograms, ischemic time and histopathological findings.

Plasma brain natriuretic peptide as a surrogate marker for cardioembolic stroke

BackgroundCardioembolic stroke generally results in more severe disability, since it typically has a larger ischemic area than the other types of ischemic stroke. However, it is difficult to differentiate cardioembolic stroke from non-cardioembolic stroke (atherothrombotic stroke and lacunar stroke). In this study, we evaluated the levels of plasma brain natriuretic peptide in acute ischemic stroke patients with cardioembolic stroke or non-cardioembolic stroke, and assessed the prediction factors of plasma brain natriuretic peptide and whether we could differentiate between stroke subtypes on the basis of plasma brain natriuretic peptide concentrations in addition to patient's clinical variables.MethodsOur patient cohort consisted of 131 consecutive patients with acute cerebral infarction who were admitted to Kagawa University School of Medicine Hospital from January 1, 2005 to December 31, 2007. The mean age of patients (43 females, 88 males) was 69.6 ± 10.1 years. Sixty-two patients had cardioembolic stroke; the remaining 69 patients had non-cardioembolic stroke (including atherothrombotic stroke, lacunar stroke, or the other). Clinical variables and the plasma brain natriuretic peptide were evaluated in all patients.ResultsPlasma brain natriuretic peptide was linearly associated with atrial fibrillation, heart failure, chronic renal failure, and left atrial diameter, independently (F4,126 = 27.6, p < 0.0001; adjusted R2 = 0.45). Furthermore, atrial fibrillation, mitral regurgitation, plasma brain natriuretic peptide (> 77 pg/ml), and left atrial diameter (> 36 mm) were statistically significant independent predictors of cardioembolic stroke in the multivariable setting (Χ2 = 127.5, p < 0.001).ConclusionIt was suggested that cardioembolic stroke was strongly predicted with atrial fibrillation and plasma brain natriuretic peptide. Plasma brain natriuretic peptide can be a surrogate marker for cardioembolic stroke.