P12 SUBCUTANEOUS IMPLANTABLE CARDIOVERTER–DEFIBRILLATOR AFTER TRANSVENOUS LEAD EXTRACTION: SAFETY, EFFICACY AND OUTCOME

Background

Subcutaneous implantable cardioverter defibrillator (S–ICD) is a suitable alternative for trans–venous–ICD (TV–ICD) patients underwent transvenous lead extraction (TLE) for any reason, but limited data are available about outcome of s–ICD patients implanted after TLE.

Methods

Thirty–six consecutive patients underwent TLE of TV–ICD and subsequent S–ICD implantation in our center were included in this prospective single–center observational study (72.2% male, median age 52 years–old).

Results

During a median follow-up of 31 months, 3 patients (8.3%) experienced appropriate therapy and 7 patients (19.4%) experienced complications including innapropriate therapy (IAT) (n = 4; 11.1%), pulse generator decubitus with no evidence of infection (n = 2; 5.5%) and ineffective therapy (n = 1; 2.7%). Reasons of IAT were: T–wave oversensing in one patient and extracardiac signals in the remaining 3 patients. Of note, 2 patients who experienced IAT had a left–ventricular assist device (LVAD) for refractory heart failure (HF). Premature device explantation and TV–ICD re–implantation occurred in 4 patients (11%) for pulse generator decubitus despite surgical pocket revisions (n = 2), for recurrent IAT despite reprogramming (n = 1) and ineffective therapy during arrhythmic storm (n = 1). Eight patients (22.2%) died, 3 patients (9%) underwent LVAD implantation due refractory HF during follow-up. Six patients died because of refractory HF, 1 patient died due to intracerebral hemorrhage and 1 due to sarcoidosis. There were no documented deaths associated with the procedure or the S–ICD system itself. No patient had the device removed because of a perceived need for antitachycardia pacing (ATP) or the necessity of pacing or cardiac resynchronization therapy despite 9 patients (25%) after TLE of a two–chamber ICD and one patient (3%) after TLE of a CRT–D. Univariate predictors of death included hypertension (HR 22.72; p = 0.02), diabetes (HR 10.64; p = 0.001), ischemic heart disease (HR 5.92; p = 0.01) and NYHA class > = II (p = 0.04). We did not observed any predictors for complications including IATs and device-related complications requiring surgical revision.

Conclusions

S–ICD implantaion after TLE of TV–ICD is safy and effective. Baseline clinical characterisctics including ischemic heart disease, diabetes, hypertension and NYHA class > = II are associated with worse survival.

Impact of ablation index settings on pulmonary vein reconnection

PURPOSE

Ablation index (AI) is a radiofrequency lesion quality marker. The AI value that allows effective and safe pulmonary vein isolation (PVI) is still debated. We evaluated the incidence of acute and late PV reconnection (PVR) with different AI settings and its predictors.

METHODS

The Ablation Index Registry is a multicenter study that included patients with paroxysmal/persistent atrial fibrillation (AF) who underwent first-time ablation. Each operator performed the ablation using his preferred ablation catheter (ThermoCool® SmartTouch or Surround Flow) and AI setting (380 posterior-500 anterior and 330 posterior-450 anterior). We divided the study population into two groups according to the AI setting used: group 1 (330-450) and group 2 (380-500). Incidence of acute PVR was validated within 30 min after PVI, whereas the incidence of late PVR was evaluated at repeat procedure.

RESULTS

Overall, 490 patients were divided into groups 1 (258) and 2 (232). There was no significant difference in the procedural time, fluoroscopy time, and rate of the first-pass PVI between the two study groups. Acute PVR was observed in 5.6% PVs. The rate of acute PVR was slightly higher in group 2 (64/943, 6.8%, PVs) than in group 1 (48/1045, 4.6% PVs, p = 0.04). Thirty patients (6%) underwent a repeat procedure and late PVR was observed in 57/116 (49%) PVs (number of reconnected PV per patient of 1.9 ± 1.6). A similar rate of late PVR was found in the two study groups. No predictors of acute and late PVR were found.

CONCLUSION

Ablation with a lower range of AI is highly effective and is not associated with a higher rate of acute and late PVR. No predictors of PV reconnection were found.

P527Ultrasound-guided serratus anterior plane block for S-ICD implantation using the intermuscular technique

Funding Acknowledgements

NONE

Background

operative anesthetic requirements and peri-operative discomfort are barriers to wide adoption of the subcutaneous implantable cardioverter defibrillator (S-ICD) system expecially when the intermuscular technique is used due to the greater amount of tissue dissection. The procedure is most commonly performed under general anesthesia (GA). There is growing interest in transitioning away from the routine use of GA and towards several alternative anesthesia modalities implifying the anesthetic management of the S-ICD implant procedure without the involvement of an anesthesiologist.

Purpose

we assessed the feasibility of ultrasound-guided serratus anterior plane block (US-SAPB) in patients undergoing S-ICD implantation with the intermuscular two-incision technique. Methods: the study population included 38 consecutive patients (84% male; median, 53 [46-62] years) who received S-ICD implantation using the intermuscular two-incision technique. All procedures were performed under US-SAPB and sedoanalagesia without the involvement of an anesthesiologist.

Results

the average procedure time was 67 ± 14 minutes.No patient experienced significant hemodynamic changes or oxygen desaturation during the period of US- SAPB procedure and sedation; there was no need for pharmacological interventions. The whole procedute was well tollerated without discomfort and complications in the absence of needing GA except in one (2.6%) patient who required GA with laryngeal mask airway. Patients remained always able to respond appropriately to neurological monitoring during S-ICD implantation procedure. There were no procedure-related complications.

Conclusion

US-SAPB and the intermuscular two-incision technique may be a safe and feasible promising combination for S-ICD implantation overcoming potential barrier to wieder S-ICD adoption in the clinical practice.

P5688Is renal dysfunction associated with the outcome of CRT patients?

Background

The benefit of cardiac resynchronization therapy (CRT) in patients (pts) with chronic kidney disease (CKD) remains controversial despite frequent use. Pts with impaired renal function have systematically been excluded from randomized clinical trials and therefore specific recommendations for the use of CRT in these pts are still lacking.

Purpose

Study objectives were to assess long-term outcomes and clinical/echocardiographic response in a large population of patients with moderate-to-severe impaired renal function implanted with a CRT device in accordance with the current standard of care.

Methods

We prospectively analyzed clinical, instrumental data and survival of pts with CKD who received a CRT device in the CRT-MORE registry from 2011 to 2014. Adverse events for the analysis of clinical outcome comprised death from any cause and nonfatal HF events requiring hospitalization after CRT implantation. LV reverse remodeling and Clinical Response (CR) were also evaluated at 12-month follow-up. Patients were stratified according to current definition of CKD stage: low-moderate CKD with a GFR = 45–59 mL/min (stage 3A); moderate CKD with a GFR = 30–44 mL/min (stage 3B) and severe CKD with a GFR = 15–29 mL/min (stage 4).

Results

Of the 922 consecutive patients enrolled in the registry, 416 (45%) pts had a moderate-to-severe impaired renal function (43% Stage 3A, 43% Stage 3B and 14% Stage 4). The mean follow-up was 935±506 days. By the end of the study, 85 pts had died and 47 pts had been hospitalized for HF. The combined end-point of death or HF hospitalization was reached by 121 (29%) pts. After 12 months the absolute LVEF improvement was greater than 10% in 37% of pts and 58% of pts displayed a positive clinical response. The percentage of pts who died was higher in the group of pts with severe CKD (32.8% vs 18.4%; p=0.012, compared to the group of pts with moderate CKD). On the contrary the percentage of pts who had at least one HF hospitalization was lower in the group with more severe CKD (2% vs 13%; p=0.011). According to CKD stage both LV remodeling (LVEF improvement ranging from 43.7% - 3A - to 30.8% - 4) and CR (positive response ranging from 63.9% - 3A - to 50% - 4) were higher in low-moderate stage and decreased with CKD severity. At multivariate Cox regression analysis adjusted for baseline confounders, CKD class at implantation [HR=1.5; 95% CI: 1.06–2.14; p=0.0219], chronic obstructive pulmonary disease [HR=1.89; 1.18–3.01; p=0.0077], persistent/permanent AF [HR=1.86; 1.15–3.01; p=0.0115] and male gender [HR=1.92; 1.07–3.46; p=0.0301] remained associated with death.

Conclusions

Among CKD patients in the CRT-MORE registry, severity of renal dysfunction at the time of CRT implantation was associated with worse prognosis, lower clinical response and LV reverse remodeling.

Acknowledgement/Funding

None

Activation mapping to determine the mechanism of atrial tachycardia when pacing techniques are not feasible

AIM

Atrial tachycardia/flutter (ATAF) could be sustained by a focus or a reentry circuit, which mapping differs significantly. Entrainment mapping is widely used to detect reentry, but it is not always feasible. We evaluated an activation mapping protocol to differentiate macro, micro-reentrant and focal ATAFs.

METHODS

Among 454 patients who underwent ablation for supraventricular tachycardia (SVT) between December, 2004 and August, 2008, 52 ATAF patients were selected and assessed by means of activation mapping (study mapping protocol). The remaining 402 cases (AVNRT, AVRT, and common atrial flutter) were excluded.

RESULTS

Fifty-eight ATAF morphologies were mapped (mean CL 297.2±98 ms). The protocol identified the ATAF mechanism in 53/58 (91%, 52 successfully ablated) morphologies, while the mapping technique failed in 5/58 (9%) cases/patients. Among the 53 ATAF diagnoses, 25/53 (47%) were macroreentrant ATAFs (MATs), whereas 12/53 (23%) were focal ATAFs (FATs) or microreentrant ATAFs (MIATs) (16/53, 30%). Ablation was successful in 25/25 cases of the MAT group, in 11/12 (91.7%) cases of the FAT group, and in 16/16 cases of the MIAT group. At the end of the procedure, no ATAF was inducible in 44/52 (85%) patients. The study protocol was successfully validated in 20 patients (10 with AVNRT, and 10 with common atrial flutter) of the control group. After a mean follow-up of 21.5±12.5 months, 36/52 (70%) pts resulted free from ATAF. Non-inducibility predicted long-term freedom from ATAF (92.1 % vs. 60 %, P=0.005, OR 0.09; 95% CI 0.18-0.51, P=0.006).

CONCLUSION

Activation mapping alone may be reliable to determine the ATAF mechanism, especially when pacing techniques are not feasible.

Long term follow up of radiofrequency catheter ablation of atrial flutter: clinical course and predictors of atrial fibrillation occurrence

OBJECTIVES

To evaluate the time to onset and the predictors of atrial fibrillation (AF) during long term follow up of patients with typical atrial flutter (AFL) treated with transisthmic ablation.

DESIGN

Prospective multicentre study.

METHODS AND RESULTS

383 patients (75.4% men, mean (SD) age 61.7 (11.1) years) who underwent transisthmic ablation for typical AFL were investigated. In 239 patients (62.4%) AF was present before ablation. Ablation proved successful in 367 patients (95.8%). During a mean (SD) follow up of 20.5 (12.4) months, 41.5% of patients reported AF. The cumulative probability of postablation AF increased continuously as time passed: it was 22% at six months, 36% at one year, 50% at two years, 58% at three years, and 63% at four years.

CONCLUSIONS

AF occurred in a large proportion of patients after transisthmic catheter ablation of typical AFL. The occurrence of AF was progressive during follow up. Preablation AF, age < 65 years, and left atrial size > 50 mm are associated with postablation AF occurrence.

Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm. A randomized study

AIMS

The aim of this prospective, randomized study was to determine the efficacy of a serial external electrical cardioversion strategy in maintaining sinus rhythm after 12 months in patients with recurrent persistent atrial fibrillation.

METHODS AND RESULTS

Ninety patients with persistent atrial fibrillation lasting more than 72 h but less than 1 year were randomized in a one to one fashion to repetition of up to two electrical cardioversions in the event of relapse of atrial fibrillation detected within 1 month of the previous electrical cardioversion (Group AGG), or to non-treatment of atrial fibrillation relapse (Group CTL). ECGs were scheduled at 6 h, 7 days, and 1 month. Clinical examination and ECGs were repeated during the 6-month and 12-month follow-up examinations. Echocardiography was repeated during the 6-month follow-up examination. Clinical and echocardiographic characteristics were similar in the two groups. All patients were treated with antiarrhythmic drugs before electrical cardioversion and throughout follow-up. After 12 months, sinus rhythm was maintained in 53% of Group AGG patients and in 29% of Group CTL patients (P<0.03). After 6 months, left ventricular ejection fraction had recovered significantly only in Group AGG (56.8 +/- 9.0% at enrollment vs 60.4 +/- 9.4% at 6 months,P <0.001).

CONCLUSION

These results demonstrate that an aggressive policy towards persistent atrial fibrillation by means of repetition of electrical cardioversion after early atrial fibrillation recurrence is useful in maintaining sinus rhythm after 12 months.

Transient complete atrioventricular block during transcatheter ablation of a left inferoparaseptal anomalous pathway in a patient with a history of previous surgical repair of ventricular septal defect

This case describes a young woman with a manifest left inferoparaseptal accessory pathway and previous history of surgical repair of a defect of the ventricular inlet septum in whom a transient complete AV block occurred during radiofrequency ablation performed from the coronary sinus. The presence of a preexisting surgery related AV block unmasked by anomalous pathway ablation is the more reliable explanation for this case.

Electrophysiological properties of the atrioventricular node and ageing: evidence of a lower incidence of dual nodal pathways in the elderly

AIMS

The purpose of this study was to investigate the relationship between the incidence of dual atrioventricular (AV) nodal pathways and age. Age-related changes in the AV node electrophysiological properties have rarely been investigated. AV nodal re-entrant tachycardia is more frequent in the young than in the elderly.

METHODS AND RESULTS

From 1988 to 1998, premature atrial stimulation was performed in 1,435 patients referred to our institution for transoesophageal electrophysiological study. 1,276 patients (89%) with a diagnosis of ventricular pre-excitation, supraventricular arrhythmia or AV block were excluded. The study cohort consisted of the remaining 159 patients (11%) of the whole group) referred for syncope (8.2% of the subgroup), suspected ventricular pre-excitation (10.7%), suspected sinus node dysfunction (52.8%) or undetermined palpitations (28.3%). The 159 study patients were divided into 3 groups according to age: group A (11-30 years, 50 patients), group B (30-60 years, 35 patients) and group C (>60 years, 74 patients). A dual AV nodal pathway was found in 16 patients of group A (32.0%), 6 patients of group B (17.1%) and 8 patients of group C (10.8%), the difference between group A and group C being significant (P<0.05).

CONCLUSION

The incidence of dual AV nodal pathways decreases with ageing, suggesting that the AV node undergoes age-related electrophysiological changes. This finding could explain the uncommon onset of AV nodal re-entrant tachycardia in the elderly.

The duration of atrial fibrillation influences the long-term efficacy of low-energy internal cardioversion

BACKGROUND

It is commonly held that long-lasting atrial fibrillation (AF), especially if associated with marked enlargement of the left atrium, is a negative predictive factor for both the recovery and the maintenance of sinus rhythm. The aim of the present study was to identify the clinical features of patients who have a greater likelihood of success both in the acute phase and, especially, in the medium-long term.

METHODS

Since June 1997, we have performed low-energy internal cardioversion to 93 patients (66 males, 27 females, mean age 62 +/- 9 years, range 26-80 years) with a mean duration of AF of 922 +/- 1032 days. Seventy-four patients had heart disease and 19 isolated AF. External cardioversion had been previously performed in 79 patients to no avail. All patients underwent antiarrhythmic therapy and were followed for a period of 13 +/- 7 months.

RESULTS

Low-energy internal cardioversion proved efficacious, restoring sinus rhythm, in 92% of patients (86/93) and inefficacious in 8% (7/93). In 24% (21/86) the procedure, although efficacious, was followed by early recurrence of AF which proved to be intractable in 52% (11/21). At the end of the session, 81% (75/93) of the patients maintained sinus rhythm. At the end of follow-up, 40% (38/93) maintained sinus rhythm. Of all the parameters considered in the two groups, the duration of AF was the only one which differed significantly between the group in sinus rhythm and that in AF, with regard to both the efficacy of the procedure in the acute phase (755 +/- 868 vs 1618 +/- 1359 days, p < 0.001) and the long-term outcome (655 +/- 5.8 vs 1107 +/- 1098 days, p < 0.05).

CONCLUSIONS

AF lasting more than 2 years constitutes a negative predictive factor for both the recovery and the long-term maintenance of sinus rhythm.

Cardioversion of persistent atrial flutter in non-anticoagulated patients at low risk for thromboembolism

BACKGROUND

The true risk of thromboembolic events after cardioversion of atrial flutter was not addressed carefully. Nevertheless, thromboembolic events were thought to be rare and less likely to occur after cardioversion of atrial fibrillation. The aim of this study was to prospectively evaluate if the interruption of persistent typical atrial flutter could be safely performed without anticoagulation in a group of patients at low risk for thromboembolic events.

METHODS

We studied 64 subjects selected among 138 consecutive patients with persistent typical atrial flutter (minimal duration 72 hours) in whom a transesophageal atrial pacing was performed in our electrophysiology laboratory from October 1994 to May 1999. Exclusion criteria included: anticoagulation therapy during the previous 4 weeks; previous history of atrial fibrillation; recent (< 1 month) myocardial infarction; history of thromboembolic events; left ventricular ejection fraction < 40%; presence of moderate or severe mitral regurgitation or stenosis; induction of sustained (> 6 hours) atrial fibrillation during transesophageal atrial pacing. Patients in whom atrial flutter persisted in spite of transesophageal atrial pacing underwent external direct current cardioversion or right atrial overdrive pacing within 24 hours. Thromboembolic events were checked for 4 weeks after the restoration of sinus rhythm.

RESULTS

Sinus rhythm was restored in 54 patients by transesophageal atrial pacing, in 8 patients by electrical cardioversion, and in 2 by right atrial pacing. The mean duration of atrial flutter was 18 +/- 19 days, the mean left atrial size 41.3 +/- 6.2 mm, and the mean left ventricular ejection fraction 54.8 +/- 7.3%. During the study period no episodes of thromboembolism were recorded.

CONCLUSIONS

Cardioversion of persistent typical atrial flutter in non-anticoagulated patients at low risk for thromboembolic events appears safe.

Right bundle branch block, intermittent ST segment elevation and inducible ventricular tachycardia in an asymptomatic patient: an unusual presentation of the Brugada syndrome?

We describe the case of an asymptomatic 54-year-old female who underwent a routine electrocardiogram (ECG) in July 1997, which showed incomplete right bundle branch block and an important ST segment elevation with a coved fashion and the inversion of T waves in leads V1-V2. Her family and personal history was free of any cardiovascular pathology. She previously underwent a routine ECG in 1991 and 1995, showing an incomplete right bundle branch block with a moderate ST segment elevation in leads V1-V2. Exercise test, 24-hour Holter ECG, echocardiogram and QT dispersion analysis were all normal. The heart-rate variability in the frequency domain revealed low vagal tone. The signal-averaged ECG was positive due to the presence of three criteria. The patient underwent an electrophysiologic study. The baseline ECG resembled the ones performed in 1991 and 1995. Sinoatrial node and atrioventricular node were normal. The HV interval resulted of 62 ms. A syncopal polymorphic ventricular tachycardia (cycle length 220 ms) interrupted by electrical defibrillation (200 J) was induced with double extrastimulus during pacing at a cycle length of 600 ms from the apex of the right ventricle. At the end of the study, one minute after a bolus of ajmaline 1 mg/kg, an important ST segment elevation in lead V1 and a left axis deviation appeared. The patient began therapy with sotalol 80 mg t.i.d. and the electrophysiologic study was repeated three days later. A non-sustained polymorphic ventricular tachycardia (cycle length 200 ms) was induced with triple extrastimulus during pacing at a cycle length of 370 ms from the outflow tract of the right ventricle. On the basis of these results and as also suggested by recent reports, we decided to implant an Automatic Implantable Cardioverter Defibrillator.

Cardiovascular adaptations to endurance training and detraining in young and older athletes

In order to evaluate the influence of aging on cardiovascular adaptations to endurance training and detraining, 12 young (range 19-25 years) and 12 older (range 50-65 years) male cyclists were examined during the training and after 2 months of detraining. Twelve young and 12 older healthy sedentary males matched for age and body surface area were used as control groups. Each subject underwent a maximal exercise test using a cycle-ergometer in order to measure maximum oxygen consumption, an M-mode and 2D echocardiography in order to assess left ventricle morphology and systolic function, and a Doppler echocardiography for evaluating the diastolic filling pattern. During the training period both groups of athletes showed higher values of maximum oxygen consumption, left ventricular wall thicknesses, end-diastolic diameter and volume, as well as left ventricular mass, than their control subjects; in the older subjects the adaptation of the heart to aerobic training seems to be obtained mainly through a higher increase in left ventricular diastolic filling. In both groups no significant modifications in the ejection fraction and diastolic function parameters were recorded. After the detraining period the wall thicknesses decreased only in young athletes, while left ventricular mass and end-diastolic diameter and volume reduced only in older athletes. In conclusion, training and detraining induced nearly similar left ventricular morphological modifications in the two age groups, even though greater in the older athletes with respect to the ventricular mass and volume. No relevant differences were observed in the Doppler filling pattern between athletes and sedentary controls.

[Immediate and long-term results of treatment of focal lesions with aortocoronary venous bypass with a stent implant]

Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty. Aim of the present study was to determine the in-hospital and long-term results of stent deployment in focal, de novo lesions of vein grafts. Thirty-five focal, de novo lesions of vein grafts in 31 patients were treated with stent deployment. Twenty-four patients (77%) had three vessels, 6 (20%) two vessels and 1 (3%) single vessel disease. Saphenous vein grafts aged 9.7 +/- 4.2 years (range 1-19 years). Twenty-two lesions (63%) were located within the body of the saphenous graft, 8 (23%) at the graft/coronary artery anastomosis and 5 (14%) at the aorta/graft anastomosis. The indications for stent deployment included: suboptimal result from balloon angioplasty (defined as > or = 50% post-angioplasty residual stenosis) in 29/35 lesions (83%); post-angioplasty coronary dissection with threatening occlusion in 4/35 (11%); abrupt closure in 2/35 (6%). Patients were screened for death, myocardial infarction, bypass surgery and repeat angioplasty during in-hospital stay and after a follow-up of 12 +/- 8 months. Even-free survival curve was constructed by the Kaplan-Meier method. Stent deployment was successful in all patients. One stent was deployed in 24/35 lesions (69%), half Palmaz-Schatz stent in 6/35 (17%) and 2 or more stents in 5/35 (14%). The balloon/vessel ratio resulted of 1.0 +/- 0.1 Minimal lumen diameter increased from 0.8 +/- 0.4 to 3.8 +/- 0.6 mm, with a mean gain of 1.8 +/- 0.6 mm (range 1.8-4.0 mm). During the in-hospital period 1 patient (3.2%) died and 1 (3.2%) had a non Q wave myocardial infarction. Therefore, the clinical success rate, was 94%. During the follow-up period, 2 patients died (6.9%), 2 (6.9%) developed a non Q wave myocardial infarction, 1 (3.4%) underwent bypass surgery and 3 (10.3%) underwent repeat angioplasty. The estimated 2-year event-free survival rate (free from myocardial infarction, repeat surgery and repeat angioplasty) was 62%. In conclusion, Palmaz-Schatz stent deployment in focal, de novo vein grafts presents a high rate of procedural success, a low rate of acute complications and good long-term results.

Intracoronary stenting for thrombus-containing lesions in the setting of acute ischemic syndromes

AIM

The presence of intracoronary thrombus was considered a contraindication for stent deployment. Recently, many investigators have demonstrated that the use of stents for thrombus-laden lesions under both elective and bail-out conditions is effective and safe, even in the setting of acute myocardial infarction (AMI).

METHODS AND RESULTS

In this study Palmaz-Schatz stents were implanted to treat suboptimal results and complications of percutaneous transluminal coronary angioplasty (PTCA) in 41 thrombus-containing lesions. Clinical presentation was unstable angina in 24 and AMI in 17 patients. Stents were deployed because of suboptimal result (n = 27), coronary dissection with threatening occlusion (n = 13) or abrupt closure (n = 1). An angiographic successful deployment was obtained in all but one lesions (98%). Four patients (9.8%) suffered from in-hospital complications: three developed a non fatal non-Q wave AMI and one died. There was no need for emergency coronary artery bypass graft surgery, repeat PTCA or blood transfusion for vascular complications. At six-months follow-up one patient (2.6%) developed a non-Q wave AMI and two (5.1%) underwent a repeat coronary angioplasty.

CONCLUSIONS

Our experience confirms that adequately dilated Palmaz-Schatz stent might be safe and effective for thrombus-containing lesions in the setting of acute ischemic syndromes.

[Coronary angioplasty in acute myocardial infarction]

Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) allows to obtain a higher reperfusion rate in the culprit vessel than thrombolytic therapy, reducing the incidence of death, non fatal reinfarction and recurrent ischemia. The aim of this study was to test the in-hospital and mid-term results of an early invasive strategy with PTCA in patients with AMI. Thirty-four patients with AMI underwent coronary angiography within 3 hours from the onset of symptoms. Twenty-four patients had anterior AMI and 3 were in cardiogenic shock. Three patients, 1 without significant lesions and 2 with multivessel diffuse coronary disease, were left out of the procedure, and 31 patients underwent PTCA. Twenty-six lesions were total occlusions with TIMI flow 0.A TIMI flow 1 was present in the other 5 vessels. Stent deployment was decided for 16 lesions (52%). Primary success (TIMI flow 3 with mean residual stenosis of 15 +/- 20%) was obtained in 30 patients (97%). In 1 patient recanalization of the anterior descending coronary artery was not possible due to tortuosity of the abdominal and thoracic aorta. At pre-discharge angiography a good result was confirmed in 24/25 patients. After 6 months only 1 patient (3%) underwent a new PTCA for recurrent angina. In conclusion, primary PTCA for AMI within 3 hours of symptom onset allows good in-hospital and mid-term results with a low rate of complications.

[Indications for heart transplant: retrospective evaluation of criteria for selection of candidates]

INTRODUCTION

Heart transplantation (HT) is a largerly accepted therapy for patients with refractory congestive heart failure. However, lack of donors imposes a rigorous choice among candidates for transplantation. Aim of this study was to identify retrospectively determinants for the selection of recipients.

METHODS

Between december 1985 and december 1993 500 patients were listed for HT at the Department of Cardiovascular Surgery of the Padua University. Among United Network for Organ Sharing (UNOS) status II patients, 42 transplanted (group I) and 38 died waiting for a donor (group II) were chosen. The following parameters were collected at the time of insertion into the waiting list: sex, blood group, diagnosis, age, body surface area, natriemia, renal function, hepatic function, presence of ventricular arrhythmias, use of ACE-inhibitors, cardiac index, mean pulmonary pressure, mean wedge pressure, mean arterial pressure, central venous pressure, pulmonary arteriolar resistances, left ventricular ejection fraction. Also the time on waiting list until a final event (transplantation or death) was considered.

RESULTS

Comparing the two groups the diagnosis of dilated cardiomyopathy (59.4% group I vs 36.8% group II; p = 0.04) and ejection fraction (26.4 +/- 9.1% group I vs 22.2 +/- 8.0% group II; p = 0.03) were the only variables statistically different. Multivaried analysis evidenced some parameters as independent predictors for HT. In detail, being listed for HT for more than 6 months lowered the probability to receive a heart to 0.34, while waiting for more than 12 months increased it to 2.64. Mean arterial pressure higher than 75 mmHg increased the probability for HT to 2.87, while an increase in mean pulmonary pressure of 5 mmHg lowered the probability to 0.80. An increase in the cardiac index of 0.5 l/m1/m2 lowered the probability to 0.61. A blood group other than 0 increased the possibility to 3.60, the basal surface area higher than 1.78 m2 lowered it to 0.306 and an ejection fraction higher than 22% increased it to 3.94.

CONCLUSIONS

We can conclude that parameters which predict the outcome of patients listed for HT were not only size matching, blood group and waiting time, but also ejection fraction, arterial pressure and diagnosis.

[Percutaneous mitral valvuloplasty in mitral restinosis after surgical commissurotomy]

The frequency of mitral restenosis after surgical commissurotomy has been estimated between 10 and 30% up to 10 years and 85% up to 28 years. Aim of this study was to analyze the results of balloon mitral valvuloplasty (BMV) in a series of patients with previous surgical commissurotomy.

METHODS

Between December 1988 and December 1995 432 patients underwent BMV. Of these patients, 30 (6.9%; 10 men, 20 women, aged 53 +/- 12 years) had recurrent mitral stenosis after surgical commissurotomy. Contraindications to BMV were the evidence of left atrial thrombi at transesophageal echocardiography and/or of mitral insufficiency > 2+/4+. The Inoue's single balloon catheter was used for all the procedures.

RESULTS

BMV resulted in a decrease in mean mitral gradient from 12.6 +/- 3.8 to 6.1 +/- 2.9 mmHg, and an increase in mitral valve area from 1.03 +/- 0.19 cm2 to 1.95 +/- 0.40 cm2. A mitral insufficiency > or = 3+/4+ occurred in 4/30 BMV (13%). At follow-up (mean 27 +/- 18 months) 20/26 patients (77%) remained clinically improved: 54% were in NYHA class I and 23% in class II.

CONCLUSIONS

BMV is an effective short- and long-term procedure for patients with previous surgical commissurotomy, with a low additional risk of complications. Thus, BMV can be considered the treatment of choice in these patients.

Efficacy of intravenous propafenone in termination of atrial flutter by overdrive transesophageal pacing previously ineffective

Fifty patients with symptomatic type I atrial flutter in whom termination of the arrhythmia with transesophageal stimulation was unsuccessful were randomized to undergo a repeat procedure after intravenous propafenone (n = 25) or placebo (n = 25). Immediate sinus rhythm recovery rate was 36% in the propafenone group and 4% in the placebo group (p = 0.005), indicating that intravenous propafenone increases the rate of successful transesophageal stimulation and can be used when a first attempt at conversion is ineffective.