Journal of cardiovascular medicine
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J Cardiovasc Med (Hagerstown) · Aug 2010
ReviewUnloading therapy by intravenous diuretic in chronic heart failure: a double-edged weapon?
A well established part of therapeutic approaches applying to cases of chronic heart failure (CHF) with extreme fluid retention is represented by intensive intravenous (i.v.) therapy with loop diuretics. This kind of therapy, if appropriately modulated according to the individual clinical picture and biohumoral pattern, is able to decrease the abnormally high ventricular filling pressures, thereby relieving the breathlessness while being able to retrieve a suitable urine output, so as to propitiate regression or disappearance of edema without unfavorable influences on renal clearance of nitrogenous compounds. Nevertheless, the intensive i.v. diuretic therapy should be tailored on the basis of a close assessment of baseline hemodynamic data and hemodynamic response to the medications, in addition to the careful diuretic dose titration and cautious evaluation of risk/benefit ratio. ⋯ The measures, thought to be able to prevent renal arterial constriction and to impede deterioration of glomerular filtration rate (GFR) due to the ischemic-necrotic tubular injury, as occurring in the set of intensive unloading therapy with i.v. furosemide or other loop diuretic, are represented by application of inotropic and renal vasodilator support by dopamine i.v. infusion at low doses or by other inotropic agents provided with recognized renal vasodilator properties and/or by addition to i.v. furosemide of osmotic agents able to expand the hematic volume, so counteracting or minimizing the reflex renal vasoconstriction induced by furosemide-related reduction in intravascular circulating volume: i.v. infusion of small volumes of hypertonic saline solution, as well as administration of albumin, mannitol and/or plasma expanders. Because renal impairment, as developing in the setting of CHF, has proven to represent a very important indicator of adverse outcome, every effort should be addressed to prevent any significant (>25% of basal value) rise in serum creatinine consequent to diuretic unloading therapy or to other procedures (paracentesis of tense ascites, ultrafiltration) aimed at rapid fluid removal in edematous or ascitic CHF or cardiogenetic anasarca. Ultrafiltration, even though a promising technique highly valued for its acknowledged property to obtain a more rapid fluid and weight loss in CHF patients with marked fluid retention, has been demonstrated so far to produce neurohumoral activation, creatinine abnormalities and symptomatic hypotensions similar to those due to i.v. loop diuretics; thus, the hypothesized advantages of this technique remain to be further clarified and confirmed, with regard to its safety profile and cost-effectiveness.
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J Cardiovasc Med (Hagerstown) · Aug 2010
Comparative StudyPredictive value of cardiac troponin-I compared to creatine kinase-myocardial band for the assessment of infarct size as measured by cardiac magnetic resonance.
The estimation of infarct size by biochemical myocardial necrosis markers is used in current clinical practice, rather than the more expensive and not always available imaging techniques. However, for this purpose, the peak value of serum biomarkers can overestimate the necrotic area, especially after reperfusion. ⋯ In patients with a first acute myocardial infarction, cTnI value assessed at 72 h from symptom onset shows the best correlation with predischarge infarct volume as assessed by DE-CMR and is superior to cTnI and creatine kinase-myocardial band peak and total values.
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J Cardiovasc Med (Hagerstown) · Aug 2010
Case ReportsPostinfarction septal dissection and rupture evolved as an inferobasal pseudoaneurysm: a specific anatomical pattern.
In rare cases of posterior myocardial infarction, septal rupture is the consequence of a dissecting interventricular hematoma that evolves as a fibrotic septal chamber with two separate communications, towards left and right ventricle. This unusual anatomical pattern is generally unsuspected and described as a normal interventricular defect associated with a basal left ventricular aneurysm or pseudoaneurysm. We present a case where echocardiography and ventricular angiography did not detect this situation. As surgical implications are important, this peculiar anatomical pattern should be suspected especially in patients with asymptomatic postinfarction posterior septal rupture or in those with minimal clinical impairment.
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J Cardiovasc Med (Hagerstown) · Jul 2010
Randomized Controlled Trial Multicenter Study Comparative StudyA multicenter randomized study to evaluate intracoronary abciximab with the ClearWay catheter to improve outcomes with Lysis (IC ClearLy): trial study design and rationale.
Percutaneous coronary intervention (PCI) is a highly effective therapy for acute ST-elevation myocardial infarction. Adjunctive therapy with platelet glycoprotein (GP) IIb/IIIa inhibitor can result in increased vessel patency and improved outcomes in ST-elevation myocardial infarction patients undergoing PCI. The investigation of novel dosing and delivery strategies of this therapy may help to further improve outcomes. ⋯ The purpose of this study is to evaluate whether an intracoronary bolus of abciximab delivered with the ClearWay RX catheter prior to the 12 h post-PCI intravenous infusion regimen of abciximab will result in significant additional clot resolution in vivo and improved myocardial perfusion when compared with an intravenous bolus of abciximab on top of the 12 h post-PCI intravenous infusion regimen of abciximab as per standard practice. The primary endpoint chosen to evaluate this hypothesis is infarct size as assessed by cardiac magnetic resonance.
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J Cardiovasc Med (Hagerstown) · Jul 2010
Comparative StudyOff-pump coronary revascularization in chronic dialysis-dependent patients: early outcomes at a single institution.
Atherosclerotic vascular disease is the leading cause of morbidity and mortality in patients with end-stage renal disease. Several authors reported that chronic dialytic patients have a high operative risk when submitted to coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB) whereas little information exists about off-pump myocardial revascularization in these patients. ⋯ In our experience, avoidance of CPB in end-stage renal disease patients was associated with an acceptable incidence of postoperative complications and of major adverse events. Off-pump CABG is a safe and effective method of myocardial revascularization in chronically dialyzed patients that should strongly be taken in consideration when planning the surgical strategy in this selected cohort of patients, although multicentric prospective randomized controlled trials are strongly recommended.