Sustained Myocardial Infarction Research Articles

Anomalous Origins of All Three Coronary Arteries from Separate Ostia within the Right Aortic Cusp: A Case Report and Review of the Literature.

Coronary artery anomalies are congenital defects which are found incidentally or after cardiac events. While these are rare abnormalities with the majority of patients remain asymptomatic and largely undiagnosed, it remains to be a major cause of sudden cardiac death (SCD). Anomalous origin of left coronary artery (ALCA) from the opposite right aortic sinus is extremely rare with less than 100 cases reported to-date. These patients are at increased risk for significant cardiac events, including SCD. In this report, we present a 48-year-old man with hypertension and marijuana use who was admitted initially with multi-lobar pneumonia and acute kidney injury, developed respiratory failure and sustained ST elevation myocardial infarction (STEMI). Coronary angiography demonstrated anomalous origin of all three main coronary arteries arising from right aortic sinus. In this report we also discuss the genesis of this rare and potentially fatal congenital abnormality and we highlight the diagnostic and management strategies available to-date.

The hybrid algorithm in treatment of coronary chronic total occlusions - MSWiA Lublin CTO 5-year registry.

IntroductionTreatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates.AimOur single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients.Material and methodsBetween January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 – easy, 1 – intermediate, 2 – difficult, ≥ 3 – very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported.ResultsTwo hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% – 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis).ConclusionsThe hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.

P5538Safety and efficacy of acetylcholine provocation test for diagnosis of vasospastic angina in young patients

Abstract Background Vasospastic angina (VSA) is considered as a cause of myocardial infarction with nonobstructive coronary arteries. Given the previous reports of higher incidence of cardiovascular events in young VSA patients, early diagnosis and optimal treatment are important for these patients. While acetylcholine provocation test (ACh test) for VSA diagnosis is well reported, ACh test among young patients is not as commonly performed, therefore its safety and usefulness for this patient subset have not been fully evaluated. Purpose The purpose of this study was to evaluate the safety and the proportion of positive results of ACh test for young patients. Methods Data from patients who underwent ACh test in our institution from May 2012 to September 2018 were retrospectively analyzed. A total of 669 patients were enrolled and divided into 2 groups according to age: Young group (Age≤50, n=106); and Senior group (Age&gt;50, n=563). Results The senior group had a higher incidence of hypertension, dyslipidemia, diabetes mellitus, and coronary artery disease. On the other hand, the young group had a significantly higher incidence of current smoker and tendency of daily alcohol. The rate of positive ACh test was similar, and there were no significant differences in major or minor complications between the 2 groups. Patient characteristics and outcome Young group Senior group p (n=106) (n=563) Age (years) 42.8±7.3 68.0±9.0 &lt;0.001 Male (%) 56.6 52.2 0.407 Current smoker (%) 34.9 15.4 &lt;0.001 Daily alcohol (%) 31.1 22.9 0.070 Hypertension (%) 33.0 66.6 &lt;0.001 Dyslipidemia (%) 50.0 68.4 &lt;0.001 Diabetes (%) 12.3 20.8 0.047 ACh positive (%) 52.8 49.9 0.581 Minor adverse event (%) 4.7 5.9 0.820 Major adverse event (%) 0.9 1.4 1.000 Major adverse event: composite of death, ventricular fibrillation, sustained ventricular tachycardia (VT), myocardial infarction and stroke. Minor adverse event: non-sustained VT and paroxysmal atrial fibrillation. Conclusion ACh provocation test for young patients can be safely performed, and the rate of positive results was similar to that of senior patients. In young patients suspected of having VSA, ACh test should be actively performed to identify optimal medical therapy for prevention of cardiovascular events. Acknowledgement/Funding None

A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

BACKGROUND:The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).METHODS:Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.RESULTS:After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05–1.39]; P = .01) and mortality (OR, 1.81 [1.39–2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98–1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59–0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58–0.97]; P = .03), and mortality (OR, 0.58 [0.41–0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03–1.40]; P = .02).CONCLUSIONS:Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

CARDIAC EFFECTS OF COMBINED SGLT 1/2 INHIBITION FOLLOWING EXPERIMENTAL MYOCARDIAL INFARCTION IN THE RAT

Dual SGLT1/2 inhibition offers the potential to not only increase glucosuria beyond that seen with selective SGLT2 inhibition alone but to reduce glucose absorption from that gut as well and to stimulate glucagon-like peptide 1 (GLP-1) secretion. However, beyond the kidney and gut, SGLT1 is expressed in other organs including the heart where it potentially assists GLUT-mediated glucose transport. Since cardiac myocytes become more reliant on glucose as a fuel source in the setting of stress, this study sought to compare the effects of dual SGLT1/2 inhibition with selective SGLT2 inhibition in the diseased heart. Hyperglycaemic Fischer F344 rats were randomized to receive either vehicle, the dual SGLT1/2 inhibitor, T-1095, or the selective SGLT2 inhibitor, dapagliflozin. Animals were then further randomized to undergo sham surgery or ligation of the left anterior descending (LAD) coronary artery. Cardiac function was assessed prior to termination 4 weeks later that was followed by assessment of cardiac structure and expression of glucose transporters GLUT1, GLUT4 and SGLT1. Dapagliflozin and T-1095 induced glucosuria to a similar extent in both the control and myocardial infarction settings with similar effects on glycaemia. Neither dapagliflozin nor T-1095 had any demonstrable effect on cardiac function or structure in the control setting. Following myocardial infarction, however, significant (p < 0.05) differences were noted. When compared with vehicle or dapagliflozin-treated animals, rats that received T-1095 displayed worse cardiac function as evidenced by (i) lower EF, (ii) reduced dP/dt max, (iii) impaired isovolumic relaxation in diastole (dP/dt min), (iv) prolongation of Tau, and (v) increase in the end-diastolic pressure volume relationship (EDPVR). While vehicle and dapagliflozin-treated rats underwent hypertrophic changes following myocardial infarction this did not occur in animals that had received T-1095. Following myocardial infarction, lung weight was higher in T-1095 treated rats than in those animals that had received either vehicle of dapagliflozin. Notably, expression of GLUT 1 and GLUT4 were reduced in the hearts of all animals that had sustained myocardial infarction while that of SGLT1 was unchanged. T-1095 prevented the hypertrophic response following experimental myocardial infarction in the rat with adverse consequences on both systolic and diastolic function. The reduction in GLUT expression post-MI suggests that the heart may be more reliant on SGLT1-mediated glucose transport in the disease setting. These findings suggest the need for caution with dual SGLT1/2 inhibition in patients with diabetes at high cardiovascular risk.

Thrombophilia in 153 Patients With Premature Cardiovascular Disease ≤Age 45.

We assessed contributions of thrombophilia to premature cardiovascular disease (CVD) events (≤ age 45) in 153 patients. Test results of thrombophilia-hypofibrinolysis were obtained in 153 patients with CVD ≤ age 45, 110 healthy normal controls, and 110 patients who had venous thromboembolism (VTE) without CVD. Of the 153 patients with CVD, 121 (79%) had sustained myocardial infarction, 70 (46%) had coronary artery stenting, and 53 (35%) had coronary artery bypass grafts. The first CVD events occurred at ages >20 to 35 in 47 patients and at ages >35 to 45 in 106 patients. At study entry, median low-density lipoprotein cholesterol was 126 mg/dL, 56 (37%) smoked, 56 (37%) had hypertension, and 56 (37%) were diabetic. Cases differed from normal controls for high factor VIII (10 [22%] of 45 vs 7 of 103 [7%], P = .007), high homocysteine (32 [21%] of 151 vs 5 [5%] of 107, P = .0002), low free protein S (5 [11%] of 44 vs 2 [2%] of 96, P = .032), high anticardiolipin antibodies (ACLA) IgM (11 [9%] of 129 vs 2 [2%] of 109, P = .024), high lipoprotein (a) [Lp(a)] (46 [30%] of 151 vs 21 [19%] of 110, P = .038), and the lupus anticoagulant (4 [11%] of 37 vs 2 [2%] of 110, P = .035). There were no differences ( P > .05) between cases and VTE controls except free protein S and Lp(a). Free protein S was more often low in VTE controls (24 [28%] of 85 vs 5 [11%] of 44, P = .03) and Lp(a) was more often high in cases (46 [30%] of 151, VTE controls 12 [17%] of 71, P = .032). In 153 patients with premature CVD ≤ age 45, thrombophilia was pervasive (high factor VIII, homocysteine, ACLA IgM, low free protein S, high Lp(a), and lupus anticoagulant), evidencing thrombotic contribution to premature CVD. Moreover, thrombophilia in patients with premature CVD was comparable to VTE controls, emphasizing the pervasive nature of thrombophilia in premature CVD.

Venovenous Extracorporeal Membrane Oxygenation With Prophylactic Subcutaneous Anticoagulation Only: An Observational Study in More Than 60 Patients

Extracorporeal lung support and therapeutic anticoagulation are dogmatically linked for most clinicians in fear of clotting of the extracorporeal circuit. In the last decade, however, we have learned that bleeding complications in the course of extracorporeal membrane oxygenation (ECMO) therapy are common and not occasionally limiting or fatal. Even though international guidelines lowered the PTT-target values, ECMO therapy without anticoagulation has only been reported sporadically in case reports heretofore. This monocentric, observational study was designed to evaluate a protocol for venovenous ECMO therapy without additional anticoagulation. Patients without former thrombotic events solely received thrombosis prophylaxis with 40 mg subcutaneous enoxaparin per day like every critical care patient. After approval by the local ethics committee (Albert-Ludwigs-University Freiburg ethics committee, EK 513/14) all consecutive patients treated with venovenous ECMO therapy since introduction of the protocol have been identified. Digital charts of the patients have been evaluated with special regard to bleeding and thrombotic or embolic events or breakdown of the extracorporeal circuit. Sixty-one patients received venovenous ECMO therapy with prophylactic subcutaneous enoxaparin only. Median duration of ECMO therapy was 7 days (2-32). Overall 560 ECMO days have been observed. No system exchange because of thrombotic occlusion was necessary within the permitted 5 days run time of the centrifugal pump. Overall we identified thrombotic complications in four patients. In three of them centrifugal pump after a runtime of more than 5 days unexpectedly stopped completely because of thrombotic occlusion. In all cases pump exchange was performed promptly and patients did not incur hypoxic deficit. One other patient received substitution of blood products and coagulation factor concentrates because of severe bleeding and sustained myocardial infarction the day after. Only 18% of patients presented with essential clinical bleeding after 7 days of therapy. No fatal bleeding event and no intracranial hemorrhage was observed. Patients required only a third of blood product transfusion compared to published data. Venovenous ECMO therapy with prophylactic anticoagulation only was feasible in this study. It was not associated with an increased rate of system exchanges compared to regimes with therapeutic anticoagulation in registry data. It provides the potential to relevantly decrease the incidence of severe bleeding events and blood transfusion requirements. The apodictic adherence to anticoagulation in therapeutic dosage should be critically scrutinized in every patient.

Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings.

Heart rate variability is a physiological feature indicating the influence of the autonomic nervous system on the heart rate. Association of the reduced heart rate variability due to myocardial infarction and the increased postinfarction mortality was first described more than thirty years ago. Many studies have unequivocally demonstrated that coronary artery bypass grafting surgery generally leads to significant reduction in heart rate variability, which is even more pronounced than after myocardial infarction. Pathophysiologically, however, the mechanisms of heart rate variability reduction associated with acute myocardial infarction and coronary artery bypass grafting are different. Generally, heart rate variability gradually recovers to the preoperative values within six months of the procedure. Unlike the reduced heart rate variability in patients having sustained myocardial infarction, a finding of reduced heart rate variability after coronary artery bypass surgery is not considered relevant in predicting mortality. Current knowledge about changes in heart rate variability in coronary patients and clinical relevance of such a finding in patients undergoing coronary artery bypass grafting are presented.

THE RATE OF METABOLIC SYNDROME AND COMORBIDITIES IN PATIENTS WITH GOUT: DATA OF A MULTICENTER TRIAL

Objective: to study the rate of metabolic syndrome (MS) and its components among gout patients in different regions of the Russian Federation. Subjects and methods. This cross-sectional multicenter study enrolled 2277 gout patients, including 1963 (86.2%) men and 314 (13.8%) women, from 12 independent medical centers in different regions of the Russian Federation. The patients over 18 years of age who met the classification criteria for gout, elaborated by S. Wallace et al., were included. The diagnosis of MS was established on the basis of Adult Treatment Panel III (ATP III) criteria. The presence of MS, its individual components and comorbidities were recorded. Results. The total rate of MS in the patients with gout was 57%; however, it varied substantially (from 15 to 77%) in different centers. Among the comorbidities, arterial hypertension was most common (in three fourths of the patients), coronary heart disease (CHD) and type 2 diabetes mellitus were less common (43 and 25%, respectively); 15% of the patients had sustained myocardial infarction, renal and cardiac failure was also observed in 15%. In the gout patients, MS was associated with the presence of CHD. Conclusion. The patients with gout were observed to have a high rate of MS (57%), its components, and cardiovascular diseases. The findings suggest that there is a relationship between the presence of MS and the development of CHD.

Impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip ® and lessons learned after the first 75 consecutive patients

Mitral valve regurgitation plays a significant role in the aetiology and course of heart failure. We investigated the impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip. Outcomes of the first 75 consecutive patients treated with MitraClip at our centre were stratified by subsequent treatment periods (25 patients each). Median total procedure time and device time decreased from 180 and 105 min in period 1 to 95 and 55 min in period 3 (P < 0.005 each). There was an excess of total safety events in period 1 (n = 16) that decreased in periods 2 and 3 (n = 6 and 3, P = 0.0003). Acute procedural success [APS; clip successfully placed and mitral regurgitation (MR) grade ≤2+ at discharge] was 80% in periods 1 and 2, but 92% in period 3 (P = 0.46). At 6 months, improvement in durability and completeness of mitral valve repair was evident: 89.4% of patients in period 3 and 65.0% in period 1 had MR ≤2+ at 6 months (P = 0.03). Within 30 days, no patient sustained myocardial infarction or stroke, and mortality was 2.7% for all patients without significant differences regarding periods. Furthermore, while treatment period did not affect mid-term survival and hospitalization for heart failure, failure of APS, STS (Society of Thoracic Surgeons) score ≥15%, and overt right heart failure at baseline predicted increased mortality. MitraClip showed a learning curve regarding mid-term durability and completeness of mitral valve repair, and APS predicted mortality. Recently published studies should be interpreted in consideration of these findings.

320-row CT: does beat-to-beat motion of the coronary arteries affect image quality?

320-row CT: does beat-to-beat motion of the coronary arteries affect image quality?

Meta-Analysis of Studies of Patients in the United Arab Emirates With ST-Elevation Myocardial Infarction Treated With Thrombolytic Agents

We performed a meta-analysis of 6 studies we conducted in the United Arab Emirates from 1995 to 2009. These included 1,262 patients with ST-elevation myocardial infarction treated with thrombolytic drugs <6 hours after onset of symptoms and signs of myocardial infarction. All patients were treated with tenecteplase or alteplase to induce coronary thrombolysis. Characteristics of patients in all studies were quite similar. Overall mean age was 47 years, 98% were men, 28% had diabetes, 25% were hypertensive, 20% were hyperlipidemic, 56% were smokers, and 9% had sustained previous myocardial infarction. Incidence of adverse outcomes of 30-day mortality (3%), reinfarction (2.5%), stroke (0.4%), or major bleeding (0%) was low compared to global experience with recanalization regardless of how it was induced. There was no incidence of major bleeding requiring transfusion or laparotomy. In conclusion, in predominantly young men in the United Arab Emirates who were admitted and treated early after onset of an acute ST elevation myocardial infarction, recanalization induced by thrombolysis was an attractive therapeutic approach.

Assessment of left ventricular volumes; reliable by gated SPECT?

Assessment of left ventricular volumes; reliable by gated SPECT?

Single-staged sequential endovascular stenting in patients with in tandem carotid stenoses

Background and purpose: Simultaneous stenoses at the origin of the internal carotid artery and the carotid siphon, also known as 'in tandem stenoses', are not uncommon. However, the clinical importance of this condition is still a subject of controversy. Surgical and endovascular approaches have been proposed to manage symptomatic patients who fail antithrombotic therapy.Methods: We present a series of eight patients with symptomatic in tandem carotid artery stenoses treated by sequential endovascular stent-assisted angioplasty. In all the cases, the intracranial stenosis was equal to, or greater, than the extracranial stenosis.Results: Procedural success, defined as residual stenosis of less than 30% in extracranial and intracranial lesions, was obtained in all the cases. No patient sustained myocardial infarction, stroke or transient ischemic attack (TIA) during the procedure or hospital stay. During a mean clinical follow-up of 12 ± 3.4 months (range: 7–20 months), there were no neurological events and on angiographic follow-up after 6 months, no patient presented in-stent de novo stenosis.Conclusion: Endovascular stent-assisted angioplasty appears to be a valid alternative for selected patients with symptomatic in tandem carotid stenoses that are refractory to medical treatment. In most of the cases, the characteristics of intracranial stenoses determine the feasibility of the procedure.

Reduced-Intensity Conditioning Is Associated with Shorter Duration of Chronic GVHD Than Myeloablative Conditioning and Provides Very Good Quality of Life for Long-Term Survivors after Allogeneic Stem Cell Transplantation.

Reduced-intensity conditioning (RIC) has been increasingly used over the last decade as a curative approach for patients (pts) not eligible for myeloablative (MA) conditioning. It is now established that RIC can allow consistent engraftment and reduce toxicity of allogeneic stem-cell transplantation (SCT). However, the long-term effects, and in particular the duration of immunosuppressive therapy (IST) needed and quality of life of long-term survivors are less defined. To explore these issues we analyzed the results of 48 pts given SCT with RIC from 1/2000 to 8/2002, such that survivors have at least 5 year follow-up, and compared them to results of 41 SCT with MA conditioning given during the same period. The RIC group included older pts than the MA group, median age 49 (range, 20–65) and 37 (range, 20–65), respectively (p=0.01). The MA group included more pts with acute leukemia/MDS (68% vs 33%, p=0.001) while pts with myeloma were only given RIC (31% of the RIC group, p< 0.001). 48% of pts in the RIC group had a prior autologous SCT compared with none in the MA group (p< 0.001). There was no difference in donor type, 26% of all pts were given SCT from unrelated donors. After a median follow-up of 6.1 years (range, 5.1–7.6) 40 pts are alive, 20 after RIC and 20 after MA conditioning with estimated survival of 42% (95ci, 28–56) and 47% (95ci, 31–63), respectively (p=NS). Long-term survival with RIC was achieved across all diagnoses including 6 of 16 pts with acute leukemia/MDS, 6 of 6 pts with CML, 3 of 11 pts with lymphoid malignancies and 5 of 15 pts with myeloma. The corresponding rates for acute leukemia/MDS, CML and lymphoid malignancies in the MA group were 13 of 28, 3 of 4 and 4 of 9, respectively. Chronic GVHD occurred in 22 pts after RIC and in 26 pts after MA conditioning with a cumulative incidence of 48% (35–65) and 66% (53–83), respectively (p=0.07). 12 of 22 pts with chronic GVHD after RIC were eventually able to stop IST, 9 died on IST (relapse-5, non-relapse mortality (NRM)-4) and only 1 of 20 long-term survivors was still on IST at last follow-up. The median duration of IST was 17 months and the cumulative probability of stopping IST after 5 years (with relapse been competing risk) was 79%. In the MA group 10 of 26 pts with chronic GVHD were able to stop IST, 8 died on IST (relapse-6, NRM-2) and 8 of 20 long-term survivors were still on IST at last follow-up. The median duration of IST was 41 months (p=0.05) and the cumulative probability of stopping IST after 5 years was 48% (p=0.001). Two women gave birth in the RIC group while 2 men in the MA group fathered children spontaneously. There was one secondary malignancy in the MA group and none in the RIC group. Two pts in the MA group sustained myocardial infarction (one fatal) compared to none of the RIC group. One pt in the RIC group had reversible nephrotic syndrome. In summary long term(>5y) survival is similar for both RIC and MA SCT, however IST is significantly shorter after RIC and quality of life seems better. Overall, all 20 pts surviving more than 5 years after RIC SCT sustained excellent quality of life and only one still required IST. The more rapid achievement of transplantation tolerance with RIC may relate to better preservation of thymic function, but this requires further investigation. These observations require further confirmation in larger registry studies.

A Phase II Study of Fixed-Dose Rate Gemcitabine Plus Low-Dose Cisplatin Followed by Consolidative Chemoradiation for Locally Advanced Pancreatic Cancer

The optimal strategy for treating locally advanced pancreatic cancer remains controversial, including the respective roles and timing of chemotherapy and radiation. We conducted a Phase II nonrandomized trial to evaluate sequential chemotherapy followed by chemoradiation in this patient population. Chemotherapy naive patients with locally advanced pancreatic adenocarcinoma were treated with fixed-dose rate gemcitabine (1,000 mg/m(2) at 10 mg/m(2)/min) plus cisplatin 20 mg/m(2) on Days 1 and 15 of a 28-day cycle. Those without evidence of extrapancreatic metastases after six cycles of chemotherapy received radiation (5,040 cGy over 28 fractions) with concurrent capecitabine (800 mg/m(2) orally twice daily on the day of radiation) as a radiosensitizer. A total of 25 patients were enrolled with a median follow-up time of 656 days. Twelve patients (48%) successfully received all six cycles of chemotherapy plus chemoradiation. Eight patients (32%) progressed during chemotherapy, including 7 with extrapancreatic metastases. Grade 3/4 hematologic toxicities were uncommon. Two patients sustained myocardial infarctions during chemotherapy, and 4 were hospitalized for infectious complications, although none in the setting of neutropenia. Median time to progression was 10.5 months and median survival was 13.5 months, with an estimated 1-year survival rate of 62%. Patients receiving all components of therapy had a median survival of 17.0 months. A strategy of initial fixed-dose rate gemcitabine-based chemotherapy, followed by chemoradiation, shows promising efficacy for treatment of locally advanced disease. A substantial proportion of patients will be identified early on as having extrapancreatic disease and spared the potential toxicities associated with radiation.

Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients

Objective To derive a risk score for the combination of death from all causes, myocardial infarction, and disabling stroke in patients with stable symptomatic angina who require treatment for angina...

Protected stent-assisted angioplasty in radiation-induced carotid artery stenosis

Objective: The surgical treatment of radiation-induced carotid stenosis is challenging and presents a high rate of complications. This has led several investigators to propose stent-assisted angioplasty as the treatment of choice for this condition. The aim of this study is to evaluate the potential risks of intra-procedural embolic stroke in this setting using cerebral protection devices.Methods: We describe our recent experience in the endovascular treatment by means of stent-assisted angioplasty with the aid of a filter cerebral protection device of eight patients presenting with radiation-induced carotid stenosis.Results: Procedural success, defined as residual stenosis of less than 30% was obtained in all cases. The mean percentage stenosis was reduced from mean 80±6.3% (range 70–90%) to 13±4% (range 10–20%). Predilation was performed in five cases, post-dilation in all the cases. Mild-to-moderate bradycardia while inflating the balloon was present in three cases and was severe in one case. No patient sustained myocardial infarction, stroke or TIA during the procedure or hospital stay. During a mean clinical follow-up of 16±7.3 months (range 5–25) there were no neurological events. On sonographic follow-up, no patient presented in-stent de novo stenosis.Discussion: Carotid angioplasty with cerebral protection can be performed safely in radiation-induced carotid stenosis with a high technical success rate. With the recent innovations and improvements in angioplasty technique, its indications and results will have to be redefined. Given the complexity and complications of surgical approaches for this condition, and the encouraging results obtained with endovascular techniques, carotid angioplasty emerges as the preferred treatment option.

Plasma fibrinogen in relation to the severity of arteriosclerosis in patients with stable angina pectoris after myocardial infarction.

Authors both of retrospective and of prospective studies have demonstrated that there is a relationship between concentration of fibrinogen in plasma and the angiographically determined severity of coronary heart disease (CHD). To determine the relevance of the plasma fibrinogen concentration for the severity of CHD, particularly in cases with additional arteriosclerotic changes in the extracranial arteries supplying the brain [cerebrovascular disease (CVD)], in the pelvic/leg arteries [peripheral occlusive arterial disease (POAD)], or in both. In a retrospective cross-sectional survey the cardiological and angiographical status of a total of 1112 male and 299 female patients with stable angina pectoris after sustained myocardial infarction and an age-matched control group of 326 male and 138 female subjects with no clinical symptoms of CHD was determined, together with measurements of plasma fibrinogen, dynamic plasma viscosity and D-dimers. More than two-thirds of the patients with arteriosclerosis had plasma fibrinogen concentrations in the uppermost tertile of the control range (men > 2.75; women > 2.83 g/l). Plasma fibrinogen concentration was correlated to the severity of CHD (for men r = 0.173, P < 0.001; for women r= 0.144, P < 0.013). Patients with generalized arteriosclerosis had higher plasma fibrinogen concentrations than did those suffering from CHD only (for men, control 2.65 +/- 0.51, CHD 3.07 +/- 0.73, CHD plus POAD 3.17 +/- 0.77 and CHD plus POAD plus CVD 3.45 +/- 0.78 g/l; for women, control 2.69 +/- 0.44, CHD 3.25 +/- 0.67, CHD plus POAD 3.19 +/- 0.77, CHD plus POAD plus CVD 3.60 +/- 0.84 g/l). Multivariate analysis showed that C-reactive protein, D-dimers and dynamic plasma viscosity accounted for 48.2% (for men) and 49.4% (for women) of the variance in plasma fibrinogen concentration. Our findings demonstrate that there is not only a correlation between plasma fibrinogen concentration and the severity of CHD, but also a correlation to the incidence of additional POAD or CVD.

Multiple Intracoronary Stenting in Native Coronary Arteries and Saphenous Vein Grafts: A Single Center Experience

Objective: To determine the early and late clinical outcomes following multiple stent deployment during a single percutaneous transluminal coronary angioplasty (PTCA) procedure. Methods: All patients who received two or more stents during a single PTCA were reviewed. An analysis was made of 114 patients (mean age = 61.2 years). A total of 268 stents were deployed, range 2–6 stents per PTCA (mean = 2.4). Stenting was performed as a primary procedure in 38 patients, for arterial dissection in 44, and for threatened closure in 32. At least two stents were deployed in the same vessel in 101 (88.6%) patients. Before discharge from hospital, there were 4 (3.6%) deaths, 6 (5.2%) patients required emergency coronary artery bypass grafting (CABG), and 2 (1.8%) patients required repeat PTCA. Three (2.6%) patients sustained acute myocardial infarction (AMI). The mean follow-up period was 10.6 months. After leaving hospital, there were no deaths, 5 (4.4%) patients required CABG, and 5 (4.4%) had a further PTCA. There was one (0.9%) AMI. The total event rate was 19.2%, which compares well with single stent trials in which event rates of 20.1% and 19.5% were reached. In addition, 19 (16.7%) patients had a recurrence of symptoms. Conclusion: It is possible to deploy multiple stents at a single intervention in the same or different vessels safely and with clinical outcomes that are similar to those in studies of single coronary stenting.