Strategy to optimize PeriproCeduraL AnticOagulation in structural transseptal interventions: Design and rationale of the STOP CLOT trial

BACKGROUND

Both transcatheter edge-to-edge repair (TEER) of mitral regurgitation or left atrial appendage closure (LAAC) require periprocedural anticoagulation with unfractionated heparin (UFH) that is administered either before or immediately after transseptal puncture (TSP). The optimal timing of UFH administration (before or after TSP) is unknown. The Strategy To Optimize PeriproCeduraL AnticOagulation in Structural Transseptal Interventions trial (STOP CLOT Trial) was designed to determine if early anticoagulation is effective in reducing ischemic complications without increasing the risk of periprocedural bleeding.

METHODS

The STOP CLOT trial is a multicenter, prospective, double-blind, placebo-controlled, randomized trial. A total of 410 patients scheduled for TEER or LAAC will be randomized 1:1 either early UFH administration (iv. bolus of 100 units/kg UFH or placebo, given after obtaining femoral vein access and at least 5 minutes prior to the start of the TSP) or late UFH administration (iv. bolus of 100 units/kg UFH or placebo given immediately after TSP). Prespecified preliminary statistical analysis will be performed after complete follow-up of the first 196 randomized subjects. To ensure blinding, a study nurse responsible for randomization and UFH/placebo preparation is not involved in the care of the patients enrolled into the study. The primary study endpoint is a composite of (1) major adverse cardiac and cerebrovascular events (death, stroke, TIA, myocardial infarction, or peripheral embolization) within 30 days post-procedure, (2) intraprocedural fresh thrombus formation in the right or left atrium as assessed with periprocedural transesophageal echocardiography, or (3) occurrence of new ischemic lesions (diameter ≥4 mm) on brain magnetic resonance imaging performed 2 to 5 days after the procedure. The safety endpoint is the occurrence of moderate or severe bleeding complications during the index hospitalization.

CONCLUSIONS

Protocols of periprocedural anticoagulation administration during structural interventions have never been tested in a randomized clinical trial. The Stop Clot trial may help reach consensus on the optimal timing of initiation of periprocedural anticoagulation.

CLINICAL TRIALS REGISTRATION NUMBER

The study protocol is registered at ClinicalTrials.gov, identifier NCT05305612.

Incidence, clinical correlates, timing, and consequences of acute thrombus formation in patients undergoing the MitraClip procedure

BACKGROUND

Despite adequate heparinization, formation of fresh intracardiac thrombi during the MitraClip procedure was reported.

AIMS

We aimed to evaluate the incidence and clinical consequences of intracardiac thrombus formation during the MitraClip device implantation.

METHODS

Clinical data and transesophageal echocardiography findings obtained during MitraClip procedures in 100 consecutive patients (81 men; mean [SD] age, 67.8 [8.3] years) were reviewed. In all patients, a heparin bolus was given immediately after a successful transseptal puncture, and the activated clotting time above 250 seconds was maintained throughout the procedure.

RESULTS

Thrombus formation was documented in 9 patients (9%). In 6 patients, thrombi formed on a transseptal needle/sheath (2 attached to the sheath in the right atrium and 4 on the sheath immediately after the puncture in the left atrium), and in 3 patients, on the MitraClip device in the left atrium (2 on a steerable guiding catheter and 1 on the clip delivery system). Overall, 6 thrombi (67%) formed prior to and 3 (33%) after heparin administration. All thrombi were transient and disappeared within minutes. No periprocedural ischemic stroke, transient ischemic attack, or other embolic complications were reported. Clinical characteristics were similar in patients with and without thrombi, except for lower left ventricular ejection fraction (LVEF; mean [SD], 23% [10%] and 30% [10%], respectively; P = 0.03). In-hospital death was reported in 6 patients: 2 with a visible thrombus and 4 without (P = 0.09).

CONCLUSIONS

Transient thrombus formation is relatively common during the MitraClip procedure, especially in patients with low LVEF; however, acute clinical consequences are benign.

[Myocardial infarction in the course of ethylene glycol poisoning--a case report]

The following paper describes the case of the 59-year-old patient moved from Clinical Cardiology to the Centre of Clinical Toxicology because of severe ethylene glycol poisoning, which occurred in the course of myocardial infarction of inferior wall. Ethylene glycol concentration was 85 mg/dl, the blood pH - 6.9, troponin >50 ng/ml, CK-MB 297.1 U/L. ECG current of injury was found at the bottom of the wall cuts reflective reductions in section ST in leads I, aVL and the precordial leads. In the coronarography was RCA occlusion, OM critical stenosis and suspected mouth of LAD stenosis. RCA urgent angioplasty was performed with implantation of bare metal stents 5. In addition, toxicological treatment consisted of mechanical ventilation, hemodialysis, ethanol, and intensive medical care. On 19 day of hospitalization the patient in good general condition was discharged home.

Thalidomide, dexamethasone and lovastatin with autologous stem cell transplantation as a salvage immunomodulatory therapy in patients with relapsed and refractory multiple myeloma

The treatment of patients with multiple myeloma usually includes many drugs including thalidomide, lenalidomide and bortezomib. Lovastatin and other inhibitors of HMG-CoA reductase demonstrated to exhibit antineoplasmatic and proapoptotic properties in numerous in vitro studies involving myeloma cell lines. We treated 91 patients with relapsed or refractory multiple myeloma with thalidomide, dexamethasone and lovastatin (TDL group, 49 patients) or thalidomide and dexamethasone (TD group, 42 patients). A clinical response defined of at least 50% reduction of monoclonal band has been observed in 32% of TD patients and 44% of TDL patients. Prolongation of overall survival and progression-free survival in the TDL group as compared with the TD group has been documented. The TDL regimen was safe and well tolerated. The incidence of side effects was comparable in both groups. Plasma cells have been cultured in vitro with thalidomide and lovastatin to assess the impact of both drugs on the apoptosis rate of plasma cells. In vitro experiments revealed that the combination of thalidomide and lovastatin induced higher apoptosis rate than apoptosis induced by each drug alone. Our results suggest that the addition of lovastatin to the TD regimen may improve the response rate in patients with relapsed or refractory myeloma.

Uric acid as a link between renal dysfunction and both pro-inflammatory and prothrombotic state in patients with metabolic syndrome and coronary artery disease

BACKGROUND

Hyperuricaemia has long been known to be associated with cardiovascular disease, and it is particularly common in patients with kidney disease, metabolic syndrome and diabetes mellitus. Metabolic syndrome is associated with pro-inflammatory and prothrombotic state.

AIM

To examine the association between renal function, serum uric acid and markers of both pro-inflammatory and prothrombotic state in patients with diabetes mellitus (DM), metabolic syndrome and coronary artery disease.

METHODS

The study population consisted of 91 patients (58 men, 33 women) aged 57.6 ± 10.3 years with metabolic syndrome and type 2 DM. Patients were selected from a large group of patients scheduled for routine coronary angiography between 2006 and 2009. The patients were evaluated for the common risk factors for atherosclerosis: smoking, hypertension, DM, family history and hyperlipidaemia. Laboratory tests included complete blood counts, serum urea and creatinine, aminotransferases, C-reactive protein (CRP), fibrinogen, uric acid, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, fasting glucose, glycated haemoglobin (HbA1c), glomerular filtration rate (GFR) and urinary protein. We also measured body mass, height, waist circumference, hip circumference and calculated body mass index (BMI) and waist-to-hip ratio (WHR).

RESULTS

The following significant correlations were observed: body mass vs serum creatinine (r = 0.291; p = 0.009), WHR vs serum creatinine (r = 0.672; p < 0.001), WHR vs GFR (r = -0.706; p < 0.001), WHR vs uric acid (r = -0.341; p = 0.001), WHR vs uric acid (r = 0.295; p = 0.05), BMI vs CRP (r = 0.231; p = 0.031), WHR vs CRP (r = 0.236; p = 0.024), serum creatinine vs uric acid (r = 0.362; p < 0.001), GFR vs uric acid (r = -0.341; p = 0.001), uric acid vs CRP (r = 0.251; p = 0.016), CRP vs fibrinogen (r = 0.470; p < 0.001), CRP vs platelet count (r = 0.282; p = 0.04) and HbA(1c) vs platelet count (r = 0.263; p = 0.0112). Multiple stepwise regression analysis showed that uric acid level was independently associated with WHR, GFR and CRP.

CONCLUSIONS

In patients with ischaemic heart disease, DM and metabolic syndrome, obesity, particularly visceral obesity, is associated with renal dysfunction and elevated markers of pro-inflammatory state. Renal dysfunction co-exists with elevated serum uric acid. Elevated serum uric acid is associated with markers of pro-inflammatory state. Markers of pro-inflammatory state correlate with prothrombotic markers such as serum fibrinogen and platelet count. Uric acid should be taken into consideration as a link between renal dysfunction and both pro-inflammatory and prothrombotic state in patients with metabolic syndrome and coronary artery disease.

Successful early percutaneous closure of acute ventricular septal rupture complicating acute myocardial infarction with Amplatzer ventricular septal occluder

Acute ventricular septal rupture - ventricular septal defect (VSD) following acute myocardial infarction remains a critical condition. We present an 80 year-old patient with an acute VSD following an acute inferior myocardial infarction. Percutaneous VSD closure with an Amplatzer ventricular septal occluder (AVSO) was performed successfully, two days after initial admission. In-hospital follow-up was uneventful. We speculate that percutaneous VSD closure with an AVSO can be an alternative to surgical correction for these patients. Despite the impressive result, this innovative approach needs further investigation and refinements before it can be recommended as the treatment of choice for acute ischemic VSD. (Cardiol J 2007; 14: 411-414).

Influence of felodipine on experimental seizures and activity of different antiepileptic drugs in mice

Effects of felodipine, the calcium channel blocker, on the electroshock, pentetrazole-, aminophylline-, and pilocarpine-induced seizures and on the anticonvulsant activity of different antiepileptic drugs against maximal electroshock were examined in mice. Felodipine increased the threshold for electroconvulsions. The drug exerted also a protective effect against pentetrazole-induced seizures, but not against aminophylline- and pilocarpine-induced seizures. The protective efficacy of diazepam and diphenylhydantoin (but not phenobarbital and valproate) against electroconvulsions was significantly enhanced by felodipine. A pharmacokinetic interaction did not seem to be responsible for the interaction of felodipine with antiepileptic drugs in the maximal electroshock test.