Adenosine-induced ST segment depression with normal perfusion

Background: Intravenous adenosine in conjunction with myocardial perfusion imaging is commonly used for the detection of coronary artery disease and risk assessment. We have previously shown that patients with ischemic changes on the 12-lead electrocardiogram (ECG) in response to adenosine but with normal perfusion pattern have a benign outcome on shortintermediate follow-up. The long-term outcome of these patients is unknown. Methods: Patients with ischemic ECG response (≥ 1 mm ST depression) to adenosine infusion but with normal perfusion on single-photon emission computed tomography (SPECT) imaging in the absence of a history of myocardial infarction or coronary revascularization were followed up for mortality, myocardial infarctions, and coronary revascularization. Results: The cohort consisted of 73 patients (81% women) who were followed up for mortality for a mean of 61 ± 15 months. There were 10 deaths, and the cause of death was determined to be non-cardiac in half of those. Follow-up for the other endpoints was complete for 21 ± 10 months during which no patient had myocardial infarction and seven underwent coronary revascularization. Conclusions: Patients with ischemic ECG response to intravenous adenosine administration and normal perfusion on SPECT are at low risk of cardiovascular events. The ST segment response to adenosine in this setting is likely related to non-ischemic mechanisms

Hypertrophic obstructive cardiomyopathy in liver transplant patients

The optimal treatment strategy for patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) and end-stage liver disease (ESLD) is not well defined. Although medical management is the accepted first line treatment, patients who are unresponsive to medication require further interventions. Since ESLD patients have a high operative risk for surgical myomectomy, alcohol septal ablation (ASA) emerges as a good alternative in these cases. The timing of ASA in relation to liver transplantation is still unclear. We report here on the first case of an orthotopic liver transplant-recipient undergoing ASA and the second of a cirrhotic patient requiring ASA as a bridge to liver transplantation. Both patients had a good clinical outcome and we argue that ASA in HOCM patients should be driven by symptom onset, and that in the asymptomatic patient it can be safely deferred until after liver transplantation. (Cardiol J 2008; 15: 74-79

The safety of bivalirudin during elective percutaneous coronary interventions in heart transplant patients

Background: Bivalirudin has been shown to be safe and effective during percutaneous coronary interventions (PCI) of native coronary arteries in the REPLACE 2 trial. The safety of bivalirudin during PCIs in heart transplant patients is not known. Methods: Heart transplant patients who had undergone PCI of de novo lesions and received bivalirudin during the procedure were included in the study. Medical records were reviewed for the occurrence of death, myocardial infarction, target vessel revascularization or major bleeding up to 30 days after discharge. The results were compared with the REPLACE 2 trial and with a control group of heart transplant recipients who received heparin during their procedures. Results: There were 51 separate PCIs performed in 30 patients in the study group. The mean age was 56 ± 12 years and 6 (20%) were women. The control group consisted of 24 patients who had undergone 35 PCIs. There were no deaths, myocardial infarctions or target vessel revascularization during the follow-up period in the study group. The combined endpoint of death, myocardial infarctions, target vessel revascularization and major bleeding requiring two or more units of packed red blood cells occurred in 2 (3.9%) patients compared to 275 (9.2%) patients in the REPLACE 2 trial (p = 0.195) and 5 (14.3%) in the control group (p = 0.115). Conclusion: Bivalirudin is a safe antithrombotic medication to use during elective PCI in heart transplant patients with cardiac allograft vasculopathy. (Cardiol J 2007; 14: 458-462

Bezpieczeństwo stosowania biwalirudyny podczas elektywnych przezskórnych interwencji wieńcowych u pacjentów po przeszczepie serca

Wstęp: W badaniu REPLACE 2 wykazano zarówno bezpieczeństwo, jak i skuteczność stosowania biwalirudyny podczas przezskórnych interwencji wieńcowych (PCI) dotyczących natywnych tętnic wieńcowych. Nie istnieją natomiast doniesienia na temat bezpieczeństwa zastosowania biwalirudyny w trakcie PCI u pacjentów po przeszczepie serca. Metody: Do badania włączono chorych po zabiegu transplantacji serca, u których wykrywane de novo zmiany w naczyniach wieńcowych zaopatrywano na drodze PCI. Za punkt końcowy badania uznano wystąpienie w ciągu 30 dni po zabiegu: zgonu pacjenta, zawału serca, konieczności wykonania rewaskularyzacji dotyczącej zaopatrywanego wcześniej na drodze PCI naczynia oraz poważnego krwawienia. Wyniki badania porównano zarówno z rezultatami REPLACE 2, jak i z wynikami uzyskanymi w grupie kontrolnej (pacjenci po przeszczepie serca otrzymujący podczas procedur PCI heparynę). Wyniki: W grupie badawczej wykonano 51 zabiegów PCI u 30 chorych. Średnia wieku w tej grupie wynosiła 56 ± 12 lat; kobiety stanowiły 20% ogółu grupy. Grupa kontrolna składała się z 24 chorych, u których wykonano 35 zabiegów PCI. W grupie badawczej podczas okresu obserwacji nie stwierdzono wystąpienia: zgonu, zawału serca lub konieczności rewaskularyzacji naczynia wieńcowego zaopatrywanego wcześniej za pomocą PCI. Złożony punkt końcowy w postaci: zgonu, zawału serca, konieczności rewaskularyzacji naczynia wieńcowego zaopatrywanego wcześniej za pomocą PCI oraz poważnego krwawienia wymagającego przetoczenia przynajmniej 2 j. koncentratu krwinek czerwonych wystąpił u 2 (3,9%) chorych w porównaniu z 275 (9,2%) pacjentami w badaniu REPLACE 2 (p = 0,195) oraz 5 (14,3%) osobami w grupie kontrolnej (p = 0,115). Wnioski: Biwalirudynę, lek o działaniu przeciwzakrzepowym, można bezpiecznie stosować w przebiegu elektywnej PCI wykonywanej u pacjentów z waskulopatią w przeszczepionym sercu. (Folia Cardiologica Excerpta 2008; 3: 29-34