Left Ventricular Diastolic Dysfunction in the Intensive Care Unit: Trends and Perspectives

Heart failure with a normal or nearly normal left ventricular (LV) ejection fraction (HFNEF) may represent more than 50% of heart failure cases. Although HFNEF is being increasingly recognized, there is a relative lack of information regarding its incidence and prognostic implications in intensive care unit (ICU) patients. In the ICU, many factors related to patient's history, or applied therapies, may induce or aggravate LV diastolic dysfunction. This may impact on patients' morbidity and mortality. This paper discusses methods for assessing LV diastolic function and the feasibility of their implementation for diagnosing HFNEF in the ICU

Angiographic estimation of atherosclerotic disease burden in a coronary artery fed by collaterals: a potential pitfall in decision for revascularization

Despite the remarkable advances in revascularization strategies made during the last decade, a significant proportion of patients are excluded from either percutaneous coronary intervention or coronary artery bypass grafting because of unsuitable coronary anatomy. Diffuse severe coronary artery disease, small vessel caliber, chronic total occlusions, or extremely calcified vessels are frequent reasons for deferring revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. We present a case concerning a middle-aged asymptomatic patient who was treated successfully with percutaneous coronary intervention due to a chronic total occlusion lesion of the left anterior descending artery. Coronary angiography is an inadequate method for the estimation of the burden of atherosclerotic disease in an artery fed by collaterals. Assessment of any residual antegrade flow, and ipsilateral and contralateral collateral filling of the segments distal to the occlusion with invasive or noninvasive techniques, could affect the appropriate decision-making by physicians

Subacute Stent Thrombosis in a Clopidogrel Resistant Octogenarian

Tel: 2610 999281, e-mail: [email protected]: An octogenarian on double clopidogrel maintenance dose (150 mg qd), due to clopidogrel resistance determined with a point-of-care assay, was subjected to percutaneous intervention (PCI) of the left anterior descending artery with two drug eluting stents. Twenty-four hours latter the patient sustained sub acute stent thrombosis manifesting as an anterior ST-elevation myocardial infarction with cardiogenic shock. Optical coherence tomography disclosed thrombus inside the stent without malapposition. Thrombus aspiration and balloon inflation of the thrombosed stent restored vessel patency. The issue of clopidogrel resistance and methods to overcome it are discussed

Telemedicine in Congenital Heart Disease

BACKGROUND: The primary rationale for the development of telemedicine has been to serve populations that have limited access to traditional, high quality medical services. These include those living in rural areas or other underserved areas, like islands, or even urban areas when a rare medical subspecialty, such as pediatric cardiology is not available. OBJECTIVE: The aim of the present study was to present our results with use of telemedicine during the European project TELEREMEDY over a period of 26 months when adult cardiologists and pediatricians of our hospital communicated with pediatric cardiologists at the tertiary Children’s Hospital “Agia Sofia” in Athens and at the Royal Brompton Hospital in London, as well as with physicians at the “Venizelio” Hospital in Crete. METHODS AND RESULTS: Over 26 months, 31 teleconference sessions were organized. During this period, 155 children with suspected congenital heart disease (CHD) underwent echocardiographic examination, which confirmed CHD in 83 (54%), acquired heart disease in 13 (8%) and normal anatomy in 59 (38%). Ventricular septal defect was diagnosed in 26/83 (31%), complex CHD in 20 (24%), atrial septal defect in 12 (14%) and patent ductus arteriosus in 8 (10%) children. Our hospital with the adult electrophysiology team was the expertise center for diagnosis and treatment of 30 children with arrhythmia. During 23 sessions with the tertiary Children’s Hospital “Agia Sofia” in Athens, an immediate transfer to the pediatric intensive care unit of the tertiary center was decided for 27 cases (17%). During 3 sessions with one participating hospital we provided consultation for 10 cases with arrhythmias. During 6 sessions with the Royal Brompton Hospital in London, rare cases of CHD, both adult and pediatric, were discussed. Two multilane conferences were organized among all participants and the systems capabilities in each hospital were discussed. CONCLUSION: Telemedicine systems, like the one used herein in the context of the TELEREMEDY program, facilitate a timely diagnosis and management of children with CHD in hospitals lacking pediatric cardiology service. In the present series, use of this program obviated unnecessary and costly transfers in 83% of cases. Thus, immediate access to specialists can guide patient management and may potentially alter the morbidity and mortality in this patient population

Magnetic resonance imaging of abnormal ventricular septal motion in heart diseases: a pictorial review

The purpose of this article is to illustrate the usefulness of MR imaging in the clinical evaluation of congenital and acquired cardiac diseases characterised by ventricular septal wall motion abnormality. Recognition of the features of abnormal ventricular septal motion in MR images is important to evaluate the haemodynamic status in patients with congenital and acquired heart diseases in routine clinical practice

Right ventricular function declines after cardiac surgery in adult patients with congenital heart disease

Right ventricular function (RVF) is often selectively declined after coronary artery bypass graft surgery. In adult patients with congenital heart disease (CHD) the incidence and persistence of declined RVF after cardiac surgery is unknown. The current study aimed to describe RVF after cardiac surgery in these patients. Adult CHD patients operated between January 2008 and December 2009 in the Academic Medical Centre in Amsterdam were studied. Clinical characteristics, laboratory tests, surgical data and intensive care unit outcome were obtained from medical records. RVF was measured by trans-thoracic echocardiography (TTE) and expressed by tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (RV S’) and myocardial performance index (MPI) pre-operatively and direct, at intermediate and late follow up. Of a total of 185 operated, 86 patients (mean age 39 ± 13 years, 54% male) had echo data available. There was a significant fall in RVF after cardiac surgery. TAPSE and RV S’ were significantly higher and MPI was significantly lower pre-operatively compared to direct post-operative values (TAPSE 22 ± 5 versus 13 ± 3 mm (P < 0.01), RV S’ 11 ± 4 versus 8 ± 2 cm/s (P < 0.01) and MPI 0.36 ± 0.14 vs 0.62 ± 0.25; P < 0.01). There were no significant differences in left ventricular function pre-operatively compared to post-operative values. Right-sided surgery was performed in 33, left-sided surgery in 37 and both sided surgery in 16 patients. Decline in RVF was equal for those groups. Patients with severe decline in RVF, were patients who underwent tricuspid valve surgery. Decline in RVF was associated with post-operative myocardial creatine kinase level and maximal troponin T level. There was no association between decline in RVF and clinical outcome on the intensive care unit. 18 months post-operatively, most RVF parameters had recovered to pre-operative values, but TAPSE which remained still lower (P < 0.01). CHD patients have a decline in RVF directly after cardiac surgery, regardless the side of surgery. Although a gradual improvement was observed, complete recovery was not seen 18 months post-operatively

Impact of renin-angiotensin system inhibitors on mortality during the COVID Pandemic among STEMI patients undergoing mechanical reperfusion : Insight from an international STEMI registry

Background: Concerns have been raised on a potential interaction between renin-angiotensin system inhibitors (RASI) and the susceptibility to coronavirus disease 2019 (COVID-19). No data have been so far reported on the prognostic impact of RASI in patients suffering from ST-elevation myocardial infarction (STEMI) during COVID-19 pandemic, which was the aim of the present study. Methods: STEMI patients treated with primary percutaneous coronary intervention (PPCI) and enrolled in the ISACS-STEMI COVID-19 registry were included in the present sub-analysis and divided according to RASI therapy at admission. Results: Our population is represented by 6095 patients, of whom 3654 admitted in 2019 and 2441 in 2020. No difference in the prevalence of SARSCoV2 infection was observed according to RASI therapy at admission (2.5% vs 2.1%, p = 0.5), which was associated with a significantly lower mortality (adjusted OR [95% CI]=0.68 [0.51 & ndash;0.90], P = 0.006), confirmed in the analysis restricted to 2020 (adjusted OR [95% CI]=0.5[0.33 & ndash;0.74], P = 0.001). Among the 5388 patients in whom data on in-hospital medication were available, in-hospital RASI therapy was associated with a significantly lower mortality (2.1% vs 16.7%, OR [95% CI]=0.11 [0.084 & ndash;0.14], p < 0.0001), confirmed after adjustment in both periods. Among the 62 SARSCoV-2 positive patients, RASI therapy, both at admission or in-hospital, showed no prognostic effect. Conclusions: This is the first study to investigate the impact of RASI therapy on the prognosis and SARSCoV2 infection of STEMI patients undergoing PPCI during the COVID-19 pandemic. Both pre-admission and in-hospital RASI were associated with lower mortality. Among SARSCoV2-positive patients, both chronic and in-hospital RASI therapy showed no impact on survival.Peer reviewe

Impact of chronic obstructive pulmonary disease on short-term outcome in patients with ST-elevation myocardial infarction during COVID-19 pandemic: insights from the international multicenter ISACS-STEMI registry

Background: Chronic obstructive pulmonary disease (COPD) is projected to become the third cause of mortality worldwide. COPD shares several pathophysiological mechanisms with cardiovascular disease, especially atherosclerosis. However, no definite answers are available on the prognostic role of COPD in the setting of ST elevation myocardial infarction (STEMI), especially during COVID-19 pandemic, among patients undergoing primary angioplasty, that is therefore the aim of the current study. Methods: In the ISACS-STEMI COVID-19 registry we included retrospectively patients with STEMI treated with primary percutaneous coronary intervention (PCI) between March and June of 2019 and 2020 from 109 high-volume primary PCI centers in 4 continents. Results: A total of 15,686 patients were included in this analysis. Of them, 810 (5.2%) subjects had a COPD diagnosis. They were more often elderly and with a more pronounced cardiovascular risk profile. No preminent procedural dissimilarities were noticed except for a lower proportion of dual antiplatelet therapy at discharge among COPD patients (98.9% vs. 98.1%, P = 0.038). With regards to short-term fatal outcomes, both in-hospital and 30-days mortality occurred more frequently among COPD patients, similarly in pre-COVID-19 and COVID-19 era. However, after adjustment for main baseline differences, COPD did not result as independent predictor for in-hospital death (adjusted OR [95% CI] = 0.913[0.658–1.266], P = 0.585) nor for 30-days mortality (adjusted OR [95% CI] = 0.850 [0.620–1.164], P = 0.310). No significant differences were detected in terms of SARS-CoV-2 positivity between the two groups. Conclusion: This is one of the largest studies investigating characteristics and outcome of COPD patients with STEMI undergoing primary angioplasty, especially during COVID pandemic. COPD was associated with significantly higher rates of in-hospital and 30-days mortality. However, this association disappeared after adjustment for baseline characteristics. Furthermore, COPD did not significantly affect SARS-CoV-2 positivity. Trial registration number: NCT 04412655 (2nd June 2020)