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A successful team treatment for left main shock syndrome

Bin QUE ; Yutong CHENG ; Hai GAO ; Xiaotong HOU ; Ran DONG ; Nan LI ; Shaoping NIE

Journal of Geriatric Cardiology.2013;(3):302-304. doi:10.3969/j.issn.1671-5411.2013.03.011

Acute myocardial infarction complicated by cardiogenic shock and left main coronary artery disease is called left main shock syndrome. It is reported that the morbility and mortality of the syndrome is approximately 0.46%and 55%-80%, respectively. However, the best treat-ment strategy in these cases is unknown. In this article, we present a patient with LMSS who successively underwent emergency percutane-ous coronary intervention and coronary artery bypass grafting with hemodynamic support within 5 days. The patient is now on his three month uneventful out-patient follow-up.

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Serum cystatin C concentration as an independent marker for hypertensive left ventricular hypertrophy

Xin LI ; Hang ZHU ; Peng LI ; Qian XIN ; Jie LIU ; Wei ZHANG ; Youhong XING ; Hao XUE

Journal of Geriatric Cardiology.2013;(3):286-290. doi:10.3969/j.issn.1671-5411.2013.03.001

Background Serum cystatin C levels can be used to predict morbidity and mortality in patients with cardiovascular disease. However, the clinical relevance of serum cystatin C levels in patients with hypertensive left ventricular hypertrophy (LVH) has rarely been investigated. We designed the present study to investigate whether serum cystatin C levels are associated with cardiac structural and functional alterations in hypertensive patients. Methods We enrolled 823 hypertensive patients and classified them into two groups:those with LVH (n=287) and those without LVH (n=536). All patients underwent echocardiography and serum cystatin C testing. We analyzed the relationship be-tween serum cystatin C levels and LVH. Results Serum cystatin C levels were higher in hypertensive patients with LVH than in those without LVH (P＜0.05). Using linear correlation analysis, we found a positive correlation between serum cystatin C levels and interven-tricular septal thickness (r=0.247, P＜0.01), posterior wall thickness (r=0.216, P＜0.01), and left ventricular weight index (r=0.347, P＜0.01). When analyzed by multiple linear regression, the positive correlations remained between serum cystatin C and interventricular septal thickness (β=0.167, P＜0.05), posterior wall thickness (β=0.187, P＜0.05), and left ventricular weight index (β=0.245, P＜0.01). Con-clusion Serum cystatin C concentration is an independent marker for hypertensive LVH.

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GRK 2 level in peripheral blood lymphocytes of elderly patients with acute myocardial infarction

Wenqian GAO ; Chunguang HAN ; Xiaochun LU ; Yongxue LIU ; Haipeng HUI ; Hao WANG

Journal of Geriatric Cardiology.2013;(3):281-285. doi:10.3969/j.issn.1671-5411.2013.03.002

Objective To investigate the G protein-coupled receptor kinase 2 (GRK 2) level in peripheral blood lymphocytes with cardiac func-tion in elderly patients with acute myocardial infarction. Methods This study enrolled 40 patients with acute ST-segment elevation myo-cardial infarction (STEMI) and 40 patients with unstable angina. All patients were 65 years or older. Cardiac function was evaluated by echocardiography, and the GRK 2 level in peripheral blood lymphocytes was measured. Patients with STEMI were followed up for 2 years. Results The GRK 2 level in peripheral blood lymphocytes was significantly higher in patients with STEMI than in patients with unstable angina, and was negatively correlated with left ventricular ejection fraction, cardiac output, stroke volume, and left ventricular fractional shortening. The GRK 2 level was significantly elevated in some patients with acute STEMI and poor cardiac function. Conclusions In-creased GRK 2 level in patients with acute STEMI may contribute to poor myocardial systolic function and myocardial remodeling. Meas-urement of the GRK 2 level in peripheral blood lymphocytes may assist in the evaluation of cardiac function and myocardial remodeling in elderly patients with acute STEMI.

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Impact of diabetes mellitus on pneumonia mortality in a senior population:results from the NHANES III follow-up study

Jian LIU

Journal of Geriatric Cardiology.2013;(3):267-280. doi:10.3969/j.issn.1671-5411.2013.03.005

Objective To examine whether diabetes mellitus increases the risk of pneumonia mortality among seniors in the U.S. general popula-tion. Methods&Results The NHANES III follow-up study data were used. After excluding individuals from other minorities, being hos-pitalized with pneumonia in the previous year at baseline, or death of pneumonia during the first year of follow-up, a total of 3,707 subjects aged 65 years or older (1,794 men and 1,913 women) who had no missing information on variables for the analysis were included. Approxi-mately 16% of seniors at baseline were diabetics, which was defined as either having been diagnosed by a physician, currently taking pills/insulin lowering blood glucose, or HbA1c higher than 6.4%. During an average 11 years of follow-up, a total of 98 deaths due to pneu-monia were recorded (ICD-10:J12-J18). Cox-regression models were used to estimate the risk association between pneumonia mortality and diabetes mellitus. After adjustment for the covariates at baseline, the hazard ratios of pneumonia death were 1.30 (95%CI:0.64-2.70) for pre-diabetics and 2.28 (95%CI:1.18-4.39) for diabetics, respectively. Among those covariates, only age (HR (95%CI);1.16 (1.13-1.20)), gender as female (0.35 (0.22-0.61)) and physical fitness measured as having no problem walking 1+mile during the previous month (0.38 (0.20-0.67)) reached statistical significance. Conclusions The results suggest that diabetes mellitus is a strong risk predictor of pneumonia mortality and the evaluation of physical fitness may also be useful in the risk prediction of pneumonia mortality for seniors.

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CHADS2 versus CHA2DS2-VASc score in assessing the stroke and throm-boembolism risk stratification in patients with atrial fibrillation:a systematic review and meta-analysis

Jiayuan CHEN ; Aidong ZHANG ; Hongyan LU ; Jun GUO ; Feifei WANG ; Zicheng LI

Journal of Geriatric Cardiology.2013;(3):258-266. doi:10.3969/j.issn.1671-5411.2013.03.004

Objective To perform a systematic review and meta-analysis of the predictive abilities of CHADS2 and CHA2DS2-VASc in stroke and thromboembolism risk stratification of atrial fibrillation (AF) patients. Methods We searched PubMed and EMBASE for Eng-lish-language literature on comparisons of the diagnostic performance between CHADS2 and CHA2DS2-VASc in predicting stroke, or sys-temic embolism, in AF. We then assessed the quality of the included studies and pooled the C-statistics and 95%confidence intervals (95%CI). Results Eight studies were included. It was unsuitable to perform a direct meta-analysis because of high heterogeneity. When analyzed as a continuous variable, the C-statistic ranged from 0.60 to 0.80 (median 0.683) for CHADS2 and 0.64-0.79 (median 0.673) for CHA2DS2-VASc. When analyzed as a continuous variable in anticoagulation patients, the subgroup analysis showed that the pooled C-statistic (95%CI) was 0.660 (0.655-0.665) for CHADS2 and 0.667 (0.651-0.683) for CHA2DS2-VASc (no significant difference). For non-anticoagulation patients, the pooled C-statistic (95%CI) was 0.685 (0.666-0.705) for CHADS2 and 0.675 (0.656-0.694) for CHA2DS2-VASc (no significant differ-ence). The average ratio of endpoint events in the low-risk group of CHA2DS2-VASc was less than CHADS2 (0.41%vs. 0.94%, P＜0.05). The average proportion of the moderate-risk group of CHA2DS2-VASc was lower than CHADS2 (11.12%vs. 30.75%, P＜0.05). Conclu-sions The C-statistic suggests a similar clinical utility of the CHADS2 and CHA2DS2-VASc scores in predicting stroke and thromboem-bolism, but CHA2DS2-VASc has the important advantage of identifying extremely low-risk patients with atrial fibrillation, as well as classi-fying a lower proportion of patients as moderate risk.

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Mechanism and management of burr entrapment：A nightmare of interven-tional cardiologists

Chiapin LIN ; Jihung WANG ; Wenling LEE ; Poming KU ; Weihsian YIN ; Tenping TSAO ; Chijen CHANG

Journal of Geriatric Cardiology.2013;(3):230-234. doi:10.3969/j.issn.1671-5411.2013.03.013

Entrapment of the burr within calcified lesion is an uncommon, but serious complication during rotational atherectomy and usually needs surgical retrieval. We report a case series of this complication and also review the possible mechanisms, such as kokesi phenomenon or insufficient pecking motion with decreased rotational speed. We also review the potential techniques ever proposed to rescue this complica-tion percutaneously, including simple manual traction, balloon dilation to release the trap, snaring the burr as distal as possible for forceful local traction and wedging the burr with a child catheter to facilitate retrieval. Gentle pecking motion of the burr for sufficient ablation and shortening the run less than 15 s may avoid such complications. Interventional cardiologists using the rotablator should be familiar with the tips and tricks to avoid and rescue this complication.

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IVUS-guided rotational atherectomy for unexpandable paclitaxel-eluting stent:A case report and review of literature

Poming KU ; Tsueiyuen HUANG ; Zhihcherng CHEN ; Max WOO ; Juisung HUNG

Journal of Geriatric Cardiology.2013;(3):226-229. doi:10.3969/j.issn.1671-5411.2013.03.014

We describe a patient suffering from late stent thrombosis in a paclitaxel-eluting stent which had an underexpanded ring due to the three-hundred-sixty-degree circumferential calcified plaque. Intravascular ultrasound (IVUS) revealed rotational atherectomy could success-fully ablate both the metallic ring and the calcified ring. The ablated segment was scaffolded with a new paclitaxel-eluting stent, well ex-panded and documented by IVUS. To our knowledge, this is the first case report of stent ablation for an unexpanded paclitaxel-eluting stent. From the Medline index, there were only six case reports of stent ablation. We review and summarize the operation details of stent ablation from these reports.

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Rotablation in the treatment of high-risk patients with heavily calcified left-main coronary lesions

Menghsiu CHIANG ; Hungtao YI ; Chengrong TSAO ; Weichun CHANG ; Chiehshou SU ; Tsunjui LIU ; Kaewoei LIANG ; Chihtai TING ; Wenlieng LEE

Journal of Geriatric Cardiology.2013;(3):217-225. doi:10.3969/j.issn.1671-5411.2013.03.009

Objective Heavily calcified left-main coronary diseases (LMCA) remain a formidable challenge for percutaneous interventions (PCI). This study was to investigate the safety and efficacy of using rotational atherectomy (RA) in treating such lesions in actual practice. Methods From February 2004 to March 2012, all consecutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were en-rolled. The relevant clinical and angiographic characteristics at the time of index PCI, as well as the clinical follow-up outcomes, were re-trieved and analyzed. Results A total of 34 consecutive patients were recruited with a mean age 77.2 ± 10.2 years. There were 82.4%pre-sented with acute coronary syndrome and 11.8%with cardiogenic shock. Chronic renal disease and diabetes were seen in 64.7%and 52.9%, respectively. Triple-vessel coronary disease was found in 76.5%of them. The mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. The angiographic success rate was 100%with a procedural success rate of 91.2%. The mean number of burrs per patient was 1.7 ± 0.5. Crossing-over stenting was used in 64.7%. Most stents were drug-eluting (67.6%). Intra-aortic ballon pump was used in 20.6%of the procedures. Three patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 31 hospital survivors, the major adverse cardiac events (MACE) rate was 16.1%, all due to target lesion revascularization or target vessel revas-cularization. Conclusions In high-surgical-risk elderly patients, plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal complication rate and low out-of-hospital MACE.

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Application of rotational atherectomy in the drug-eluting stent era

Chunchi CHEN ; Ichang HSIEH

Journal of Geriatric Cardiology.2013;(3):213-216. doi:10.3969/j.issn.1671-5411.2013.03.015

Rotational atherectomy (RA) was introduced in the interventional arena in 1988 as a dedicated device for calcified lesions. Due to the complexity of the technique, the development of alternative methods such as the cutting balloon procedure, and the high restenosis rate of subsequent bare metal stenting in long lesions, its use had later declined. However, with the increasing use of drug-eluting stents (DES) and the aggressive treatment of longer lesions, the number of procedure performed with RA has increased significantly again in recent years. In this article, we reviewed the application of RA in DES era.

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Establishment of a chronic left ventricular aneurysm model in rabbit

Cangsong XIAO ; Changqing GAO ; Libing LI ; Yao WANG ; Tao ZHAO ; Weihua YE ; Chonglei REN ; Zhiyong LIU ; Yang WU

Journal of Geriatric Cardiology.2014;(2):158-162. doi:10.3969/j.issn.1671-5411.2014.01.009

Objectives To establish a cost-effective and reproducible procedure for induction of chronic left ventricular aneurysm (LVA) in rabbits. Methods Acute myocardial infarction (AMI) was induced in 35 rabbits via concomitant ligation of the left anterior descending (LAD) coronary artery and the circumflex (Cx) branch at the middle portion. Development of AMI was co n-firmed by ST segment elevation and akinesis of the occluded area. Echocardiography, pathological evaluation, and agar i n-tra-chamber casting were utilized to validate the formation of LVA four weeks after the surgery. Left ventricular end systolic pressure (LVESP) and diastolic pressure (LVEDP) were measured before, immediately after and four weeks after ligation. D i-mensions of the ventricular chamber, thickness of the interventricular septum (IVS) and the left ventricular posterior wall (LVPW) left ventricular end diastolic volume (LVEDV) and systolic volume (LVESV), and ejection fraction (EF) were recorded by echo-cardiography. Results Thirty one (88.6%) rabbits survived myocardial infarction and 26 of them developed aneurysm (83.9%). The mean area of aneurysm was 33.4% ± 2.4% of the left ventricle. LVEF markedly decreased after LVA formation, whereas LVEDV, LVESV and the thickness of IVS as well as the dimension of ventricular chamber from apex to mitral valve annulus significantly increased. LVESP immediately dropped after ligation and recovered to a small extent after LVA formation. LVEDP progressively increased after ligation till LVA formation. Areas in the left ventricle (LV) that underwent fibrosis included the apex, anterior wall and lateral wall but not IVS. Agar intra-chamber cast showed that the bulging of LV wall was prominent in the area of aneurysm. Conclusions Ligation of LAD and Cx at the middle portion could induce develo pment of LVA at a mean area ratio of 33.4%±2.4%which involves the apex, anterior wall and lateral wall of the LV.

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