Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Long-Term Complications Related to Biventricular Defibrillator Implantation: Rate of Surgical Revisions and Impact on Survival: Insights From the Italian ClinicalService Database
- Total Arch Repair for Acute Type A Aortic Dissection With 2 Modified Techniques: Open Single-Branched Stent Graft Placement and Reinforcement of the Dissected Arch Vessel Stump With Stent Graft
- Sex and Race Differences in Right Ventricular Structure and Function: The Multi-Ethnic Study of Atherosclerosis–Right Ventricle Study
- Role of Pyruvate Dehydrogenase Inhibition in the Development of Hypertrophy in the Hyperthyroid Rat Heart: A Combined Magnetic Resonance Imaging and Hyperpolarized Magnetic Resonance Spectroscopy Study
- Cost-Effectiveness of Dabigatran for Stroke Prophylaxis in Atrial Fibrillation
- Myocardial Infarction After Carotid Stenting and Endarterectomy: Results From the Carotid Revascularization Endarterectomy Versus Stenting Trial
- Phosphorylation of Vasodilator-Stimulated Phosphoprotein Prevents Platelet-Neutrophil Complex Formation and Dampens Myocardial Ischemia-Reperfusion Injury
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Long-Term Complications Related to Biventricular Defibrillator Implantation: Rate of Surgical Revisions and Impact on Survival: Insights From the Italian ClinicalService Database
Cardiac resynchronization therapy (CRT) alone or associated with an implantable cardioverter-defibrillator (CRT-D) is now a common therapy for patients with symptomatic heart failure and evidence of ventricular dyssynchrony. Although several reports have described periprocedural adverse events and early complications of CRT implantation, long-term data on the burden of device-related untoward events are lacking. This study enrolled 3253 CRT-D patients to quantify the frequency of repeat invasive procedures and the nature of long-term complications in clinical practice and to examine possible predictors of device-related events as well as their association with long-term outcome. Four years after implantation, 50% of CRT-D patients underwent surgical revision for battery depletion and 14% for unanticipated events, such as device-related infections or lead dislodgments. For comparison, at 4 years, surgical revision for battery depletion occurred in 10% and 13% of patients who received single- and dual-chamber defibrillators at the study centers, and unanticipated events were reported in 4% and 9%, respectively. Infections occurred at a rate of 1.0%/y, and the risk of infections increased after device replacement procedures (hazards ratio, 2.04; 95% confidence interval, 1.01 to 4.09; P=0.045). Left ventricular lead dislodgements occurred at a rate of 2.3%/y and were predicted by longer fluoroscopy time and higher pacing threshold on implantation, both signs of a challenging implantation procedure. Nonetheless, device-related events were not associated with an increased risk of death. In conclusion, this study demonstrated that in current clinical practice, device-related events are more frequent in CRT-D than in single- or dual-chamber defibrillators, and frequently require surgical intervention for system revision. This information is particularly important because, although device-related events do not seem to be associated with a worse clinical outcome, they represent a source of incremental costs to the healthcare system. Therefore, efforts to reduce them could have significant financial as well as clinical benefits. See p 2526.
Total Arch Repair for Acute Type A Aortic Dissection With 2 Modified Techniques: Open Single-Branched Stent Graft Placement and Reinforcement of the Dissected Arch Vessel Stump With Stent Graft
In total arch replacement for patients with acute type A aortic dissection, anastomoses of the graft to the left subclavian artery and descending aorta are often difficult, and the arch vessel anastomosis is frequently performed at the dissected site. To reduce such problems, we performed total arch repair for acute type A aortic dissection with 2 modified techniques: open single-branched stent graft placement into the left subclavian artery and the descending aorta and reinforcement of the dissected arch vessel stump with a stent graft neointima. The initial clinical results show that open single-branched stent graft placement is a simple and effective technique for total arch repair that avoids left subclavian artery anastomosis and distal anastomosis at the descending aorta, and reinforcement of the dissected arch vessel stump with stent graft neointima is a feasible and effective technique to provide a strong dissected arch vessel stump. Therefore, with these 2 new techniques, total arch repair may become easier and safer for acute type A aortic dissection. Rigorous long-term follow-up and further extensive clinical trials are necessary before these 2 techniques can become a recommendable alternative to conventional total arch repair for acute type A aortic dissection. See p 2536.
Sex and Race Differences in Right Ventricular Structure and Function: The Multi-Ethnic Study of Atherosclerosis–Right Ventricle Study
Right ventricular (RV) morphology is an important predictor of outcomes in heart and lung disease; however, demographic differences in RV structure or function have not been studied. We found that age, sex, and race/ethnicity had important associations with RV mass and volumes and RV ejection fraction. These associations may explain differences in outcomes in a variety of common heart and lung diseases that affect the RV. We derived normative equations for RV parameters that could be used to define and diagnose RV dysfunction in adults of various races and ethnicities in research and clinical practice. See p 2542.
Role of Pyruvate Dehydrogenase Inhibition in the Development of Hypertrophy in the Hyperthyroid Rat Heart: A Combined Magnetic Resonance Imaging and Hyperpolarized Magnetic Resonance Spectroscopy Study
The primary clinical significance of this article lies in the importance of gaining a better understanding of the underlying mechanisms resulting from hyperthyroidism. Using both noninvasive and novel techniques, we have thoroughly characterized the relationship between the metabolic and functional consequences of hyperthyroidism. By studying the metabolic perturbations associated with hyperthyroidism and using this information to devise a treatment regimen to improve metabolic flexibility in the hyperthyroid heart, we have uniquely shown that the associated cardiac hypertrophy can be reduced. We have also found that under conditions of plentiful energy supply, the heart is able to alter its response to maintain cardiac output. These findings are undoubtedly important, not only for this disease but also for other metabolic diseases affecting the heart. Furthermore, the potential to study the metabolic effects of hyperthyroidism and other cardiovascular diseases in humans with the hyperpolarized techniques presented here is clear. The first trials in humans with hyperpolarized pyruvate as a metabolic biomarker are imminent and offer many advantages over other forms of metabolic assessment such as including no radiation exposure and being a minimally invasive procedure. Metabolic studies with this technology can be integrated into existing magnetic resonance imaging assessments of cardiac structure and function, as demonstrated here with a combined cine magnetic resonance imaging and hyperpolarized magnetic resonance spectroscopy assessment. See p 2552.
Cost-Effectiveness of Dabigatran for Stroke Prophylaxis in Atrial Fibrillation
Each year, in the United States alone, atrial fibrillation causes >50 000 strokes and $12 billion in medical expenditure. Thus, safe and cost-effective stroke prevention is critical to the atrial fibrillation population. Dabigatran etexilate was developed with the hope that it would be as effective as warfarin, but safer and easier to administer. The Randomized Evaluation of Long Term Anticoagulation Therapy (RE-LY) found that dabigatran 150 mg twice daily was superior to warfarin in the prevention of ischemic stroke. On the basis of results from RE-LY, the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVE), and other trials, we developed a decision-analysis model to compare the cost and quality-adjusted survival of various antithrombotic therapies. Dabigatran 150 mg (twice daily) was cost-effective in atrial fibrillation populations at high risk of hemorrhage or high risk of stroke unless international normalized ratio control with warfarin was excellent. Warfarin was cost-effective in moderate-risk atrial fibrillation populations unless international normalized ratio control was poor. See p 2562.
Myocardial Infarction After Carotid Stenting and Endarterectomy: Results From the Carotid Revascularization Endarterectomy Versus Stenting Trial
The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) showed no difference in the composite end point of stroke, myocardial infarction (MI), or death during the periprocedural period and ipsilateral stroke during follow-up. The higher risk of stroke with carotid artery stenting and higher risk of periprocedural myocardial infarction after carotid endarterectomy underscore the need for detailed analysis of the MI end point. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032), with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker positivity only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker positivity only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker positivity only remained independently associated with increased mortality. In the randomized CREST trial, both MI and biomarker positivity without symptoms or ECG changes were more common with carotid endarterectomy than carotid artery stenting. Both events were associated with increased long-term mortality in unadjusted and risk-adjusted analyses, suggesting that the occurrence of periprocedural MI or biomarker positivity only identifies a population of patients at greater risk of death in longer-term follow-up. The findings also suggest that individualized patient risk for such events may be an important consideration in the choice of carotid artery stenting or carotid endarterectomy and the choice of carotid revascularization or medical therapy. See p 2571.
Phosphorylation of Vasodilator-Stimulated Phosphoprotein Prevents Platelet-Neutrophil Complex Formation and Dampens Myocardial Ischemia-Reperfusion Injury
The formation of platelet-neutrophil complexes has significant impact on the extent of inflammatory and ischemic tissue injury. In the present study, we demonstrate that vasodilator-stimulated phosphoprotein, a crucial cytoskeletal protein involved in platelet activation, influences the formation of these platelet-neutrophil complexes. The phosphorylation of vasodilator-stimulated phosphoprotein during the reperfusion phase, achieved through the administration of prostaglandin E1 or atrial natriuretic peptide, significantly attenuates the formation of platelet-neutrophil complexes and as a result reduces the extent of myocardial ischemia-reperfusion injury. This implies that phosphorylation of vasodilator-stimulated phosphoprotein during reperfusion has cardioprotective potential and could be pursued as a future strategy to reduce myocardial reperfusion injury. See p 2579.
- © 2011 American Heart Association, Inc.
- Cost-Effectiveness of Dabigatran for Stroke Prophylaxis in Atrial Fibrillation
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