ABSTRACT: OBJECTIVE: We retrospectively assessed the incidence of hemorrhagic complications associated with pacemaker implantation in patients receiving one or more antiplatelet agents. DESIGN AND SETTING: Retrospective multicenter case-control study. Data were collected from three cardiac units in Germany from 2006 to 2010. METHODS: A total of 495 pacemaker patients were enrolled. 99 patients received dual antiplatelet therapy (aspirin and clopidogrel), 198 were given only aspirin and 198 had no antiplatelet therapy (control). Patients were matched for age and sex. Implant-related bleeding complications were defined as major bleeding, if surgical pocket exploration or blood transfusion were needed. Minor bleeding complications were defined as one or more of the following conditions: fall of hemoglobin content >1.5 g/dl not requiring blood transfusion; pocket hematoma; pocket effusion not requiring surgical revision. MEASUREMENTS AND RESULTS: Hemorrhagic complications were seen in 4/198 control patients and 6/198 aspirin-only patients [2 vs. 3 %, p = 0.5, OR = 1.52 (0.42-5.46)]. Patients undergoing dual antiplatelet therapy had significantly more bleeding complications than patients in the aspirin-only group [11/99: 11.1 vs. 3 %, p = 0.005, OR = 3.95 (1.43-11.16)]. Major complications occurred in 1/198 control patients and 2/198 aspirin-only patients [0.5 vs. 1 %, p = 0.6, OR = 2.01 (0.18-22.35)]. In contrast, 7/99 patients undergoing dual antiplatelet therapy exhibited major complications [7.1 vs. 1 %, p = 0.004, OR = 7.46 (1.52-36.50)]. CONCLUSIONS: Although in patients undergoing pacemaker implantation dual antiplatelet therapy with aspirin and clopidogrel caused a significant increase of bleeding complications, the use of aspirin alone was not associated with a significant increase in bleeding complications.
Clinical Research in Cardiology 02/2013; · 2.95 Impact Factor
ABSTRACT: Transcoronary pacing for the treatment of bradycardias during percutaneous coronary intervention (PCI) is a useful technique in interventional cardiology. The standard technique is unipolar pacing with the guidewire in the coronary artery against a cutaneous patch electrode. We developed a novel approach for transcoronary pacing by using intravascular electrodes in different positions in the aorta in a porcine model.
Unipolar transcoronary pacing was applied in 8 pigs under general anesthesia using a standard floppy guidewire in a coronary artery as the cathode with additional insulation of the guidewire by a monorail angioplasty balloon. Intravascular electrodes positioned in the aorta thoracalis and the aorta abdominalis served as indifferent anodes. The efficacy of transcoronary pacing with intravascular anodal electrodes was assessed by measurement of threshold and impedance data and the magnitude of the epicardial electrogram in comparison to unipolar transvenous pacing using the same indifferent anodal electrodes. Transcoronary pacing with the guidewire-balloon combination using indifferent intravascular electrodes was effective in all cases. Transcoronary pacing thresholds obtained against the indifferent coil electrodes in the aorta thoracalis (0.8 ± 0.5 V) and in the aorta abdominalis (0.8 ± 0.5 V) were similar to those obtained with unipolar transvenous pacing (0.7 ± 0.3 V and 0.6 ± 0.2 V, respectively), whereas the tip-electrode in the aorta thoracalis serving as indifferent anode produced significantly higher pacing thresholds (guidewire, 2.8 ± 2.6 V; transvenous lead, 1.5 ± 0.8 V). The lower pacing threshold of the coil-electrodes was associated with significantly lower impedance values (aorta thoracalis, 285 ± 63 ohm; aorta abdominalis, 294 ± 61 ohm) as compared to the tip-electrode in the aorta thoracalis (718 ± 254 ohm). The amplitude of the epicardial electrogram acquired by the intracoronary guidewire was without significant differences between the indifferent electrodes.
Transcoronary pacing in the animal model using a standard guidewire with balloon insulation and intravascular indifferent electrodes is depending on the optimal configuration of the anodal electrode. The use of intravascular coil electrodes with a sufficient surface area can produce 100% capture at thresholds comparable to transvenous pacing. Therefore, technical integration of these coil electrodes into the access sheath or the guiding catheter with respect to handling these tools in daily clinical practice in the catheterization laboratory could further facilitate the transcoronary pacing approach.
The Journal of invasive cardiology 09/2012; 24(9):451-5. · 1.84 Impact Factor
ABSTRACT: The European ST-elevated myocardial infarction (STEMI) guideline suggested the intra-aortic balloon pump (IABP) with a recommendation level I and a level of evidence C as an effective measure in combination with balloon angioplasty in patients with cardiogenic shock (CS), stent implantation, and inotropic and vasopressor support. Similarly, upon mechanical complication due to myocardial infarction (MI), the guideline suggests that in patients with a ventricular septal defect or in most patients with acute mitral regurgitation, preoperative IABP implantation is indicated for circulatory support. The American College of Cardiology/American Heart Association STEMI guideline recommends the use of the IABP with a recommendation level I and a level of evidence B if CS does not respond rapidly to pharmacological treatment. The guideline notes that the IABP is a stabilizing measure for angiography and early revascularization. Even in MI complications, the use of preoperative IABP is recommended before surgery. Within this overview, we summarize the current evidence on IABP use in patients with CS complicated by MI. From our Cochrane data analysis, we conclude that in CS due to acute MI (AMI) treated with adjuvant systemic fibrinolysis, the IABP should be implanted. In patients with CS following AMI, treated with primary percutaneous coronary intervention (PCI), the IABP can be implanted, although data are not distinctive (i.e., indicating positive and negative effects). In the future, randomized controlled trials are needed to determine the use of IABP in CS patients treated with PCI. When patients with CS are transferred to a PCI center with or without thrombolysis, patients should receive mechanical support with an IABP. To treat mechanical MI complications-in particular ventricular septal defect-patients should be treated with an IABP to stabilize their hemodynamic situation prior to cardiac surgery. Similar recommendations are given in the German Austrian guidelines on treatment of infarction-related CS patients (http://www.awmf.org/leitlinien/detail/ll/019-013.html).
Artificial Organs 05/2012; 36(6):505-11. · 2.00 Impact Factor
ABSTRACT: Thrombocyte glycoprotein IIb/IIIa inhibitors prevent fibrinogen binding and thereby thrombocyte aggregation. The inhibition
of thrombocyte activation at the damaged coronary plaque is the target of the new therapeutic strategies in treating acute
coronary syndrome. This reduces the ischemic complications associated with the non-STelevation myocardial infarction (NSTEMI)
and percutaneous coronary intervention (PCI).
Thrombocytopenia is a known complication of glycoprotein (GP) IIb/IIIa inhibitors. Although, in general, GP IIb/IIIa inhibitor-induced
thrombocytopenia is a harmless side effect which responds readily to thrombocyte transfusion, it can occasionally be a very
serious complication associated with serious bleeding. In addition patients developing thrombocytopenia have unfavorable outcome
(e.g., death, myocardial infarction, bypass surgery or additional PCI) in comparison to patients without thrombocytopenia.
Advanced age (> 65 years), low BMI and a low initial thrombocyte count (<180 000/µl) are independent risk factors of thrombocytopenia.
The risk of bleeding is higher with this form of thrombocytopenia not only due to the low thrombocyte count but also to the
impaired function of the remaining thrombocytes.
It is important to closely monitor platelet count during GP IIb/IIIa antagonist treatment. Platelet count monitoring two,
six, twelve and 24 hour after starting the treatment reveals most cases of acute thrombocytopenia. Side effects can be avoided
by the early discontinuation of the GP IIb/IIIa antagonist treatment.
This article reviews the diagnosis and treatment of glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia and summarizes
the differential diagnosis from heparin-induced thrombocytopenia and laboratory-related pseudothrombocytopenia.
Clinical Research in Cardiology 04/2012; 96(2):61-69. · 2.95 Impact Factor
ABSTRACT: Die stressinduzierte Kardiomyopathie, auch als Takotsubo-Syndrom bekannt, ähnelt einem akuten ST-Hebungsinfarkt bzw. einem
akuten Koronarsyndrom in Abwesenheit einer relevanten koronaren Herzerkrankung. Exakte epidemiologische Daten liegen bisher
nicht vor, jedoch befällt das Takotsubo-Syndrom vorzugsweise Frauen in der Menopause. Auch die genaue Pathogenese ist noch
nicht gesichert. Als häufigster beschriebener Auslöser wird plötzlich einsetzender emotionaler Stress genannt. Es gibt bis
dato keine offiziellen Leitlinien für die Therapie des Takotsubo-Syndroms. Eine symptomatische Behandlung mit Aspirin, β-Blockern
und Angiotensin-converting-Enzym-Hemmern wird empfohlen. Die ventrikuläre Kinetikstörung bildet sich normalerweise innerhalb
von 4–5 Wochen zurück. Das Takotsubo-Syndrom hat im Vergleich zum akuten Herzinfarkt eine günstigere Prognose, allerdings
können alle Komplikationen des akuten Herzinfarkts bis hin zum kardiogenen Schock auftreten.
Stress-induced cardiomyopathy, also known as takotsubo syndrome, imitates an acute ST elevation myocardial infarction or an
acute coronary syndrome, but without concomitant coronary artery disease. It mainly affects postmenopausal women, but no established
epidemiologic data of this syndrome are available to date. Furthermore, the underlying etiologies are still largely unknown.
The most frequently described trigger is strong emotional stress. Supportive therapy with aspirin, β-blockers and angiotensin-converting
enzyme inhibitors is recommended. The abnormal kinetics usually reverse or improve within 4–5 weeks. Compared with acute myocardial
infarction, takotsubo cardiomyopathy carries a favorable prognosis. However, severe complications, including ventricular fibrillation
and cardiogenic shock, may still occur.
ABSTRACT: Bei Patienten mit ST-Streckenhebungsinfarkt (STEMI) und Nicht-ST-Streckenhebungsinfarkt (NSTEMI) kommt es in ca 6–10% der
Fälle im Krankenhaus zu einem kardiogenen Schock. In den letzten Jahren scheint die Inzidenz aufgrund der invasiven Diagnostik
und Therapie nach Myokardinfarkt sich leicht zu reduzieren. Neben der ischämieinduzierten Pumpfunktionsstörung kommt der Inflammation
- vermittet durch Leukozyten- und Cytokinaktivierung - eine wichtige Rolle bei der Pathogenese und Prognose des kardiogenen
Wichtig ist die frühzeitige Diagnose, um die schnelle Revaskularisation mittels PCI und Stent im Rahmen des kardiogenen Schocks
einzuleiten und so eine deutliche Verbesserung des Überlebens zu erreichen. Mechanische Unterstützung und medikamentöse Therapien
erlauben auch bei Hochrisikopatienten eine sichere und effektive Behandung. Mechanische und pharmakologische Unterstützung
sind notwendig, um die Perfusion des Myokards und der Organe aufrecht zu erhalten. Als medikamentöse Therapie bei infarktbedingtem
kardiogenem Schock hat sich Dobutamin als Inotropikum und Noradrenalin als Vasopressor etabliert. Zur weiteren Unterstützung
liegen Daten zu Levosimendan und Erfahrungen mit PDE-IV-Hemmern vor. Dopamin und Adrenalin stehen als sekundäre Alternativen
zur Verfügung. Neue Ansätze wie NOS Inhibitoren konnte in klinischen Studien keinen Wirkvorteil belegen. Die pharmakologische
Therapie wird durch mechanische Unterstützungssysteme wie IABP, Impella oder ECMO ergänzt. Wichtig ist im Verlauf, durch organprotektive
Massnahmen die Entstehung weiterer Organdysfunktionen (Niere, Leber, Lunge ua.) zu verhindern. Die Mehrzahl der Überlebenden
des kardiogenen Schocks haben langfristig nur eine geringe funktionelle kardiale Einschränkungen, gleich bedeutend mit einer
passageren Schädigungskomponente (Stunning, Inflammation), was die Sinnhaftigkeit einer schnellen Kreislauf-unterstützenden
In patients with STEMI or NSTEMI, cardiogenic shock will occur in approximately 6–10% of cases within the hospital. Mortality
rate is still high (50–70%). However, due to early and aggressive invasive treatment of ACS patients, the incidence of cardiogenic
shock is declining. Beside ischemic injury, inflammation due to leukocyte and cytokine activation play an important role in
the pathogenesis and prognosis of cardiogenic shock patients.
Important is the early diagnosis of cardiogenic shock to initiate revascularization procedures with PCI and stents, which
have shown short- and long-term improvement in survival. Currently, mechanical support (IABP) and drug therapy (dobutamine,
norepinephrine) are necessary to stabilize myocardial and organ perfusion in high-risk patients. Firstline inotropic support
can be archived with dobutamine and norepinephrine for vasopressor support. Recently, promising data exist supporting treatment
with levosimendan in favor of PDE inhibitors for inotropic support in cardiogenic shock patients. Dopamine and epinephrine
are second line alternatives. No therapeutic benefit could be demonstrated when using novel compounds like NOS inhibitors
in CS patients. Promising effects were observed with mechanical support with rotary pumps like Impella or ECMO but need further
study. Other organ functions like liver, kidney or lung have to be monitored continuously and protective measures should be
The majority of cardiogenic shock survivors have later only slightly decreased LV function, indicating short lasting causative
injuries like inflammation or stunning. This concept supports circulatory support to overcome injury.
Intensivmedizin + Notfallmedizin 04/2012; 46(3):132-145.
ABSTRACT: We conducted the IABP Cardiogenic Shock Trial (ClinicalTrials.gov ID NCT00469248) as a prospective, randomized, monocentric clinical trial to determine the hemodynamic effects of additional intra-aortic balloon pump (IABP) treatment and its effects on severity of disease in patients with acute myocardial infarction complicated by cardiogenic shock (CS). Intra-aortic balloon pump counterpulsation is recommended in patients with CS complicating myocardial infarction. However, there are only limited randomized controlled trial data available supporting the efficacy of IABP following percutaneous coronary intervention (PCI) and its impact on hemodynamic parameters in patients with CS. Percutaneous coronary intervention of infarct-related artery was performed in 40 patients with acute myocardial infarction complicated by CS, within 12 h of onset of hemodynamic instability. Serial hemodynamic parameters were determined over the next 4 days and compared in patients receiving medical treatment alone with those treated with additional intra-aortic balloon counterpulsation. There were no significant differences among severity of disease (i.e., Acute Physiology and Chronic Health Evaluation II score) initially and no differences among both groups for disease improvement. We observed significant temporal improvements of cardiac output (4.8 ± 0.5 to 6.0 ± 0.5 L/min), systemic vascular resistance (926 ± 73 to 769 ± 101 dyn · s(-1) · cm(-5)), and the prognosis-validated cardiac power output (0.78 ± 0.06 to 1.01 ± 0.2 W) within the IABP group. However, there were no significant differences between the IABP group and the medical-alone group. Additional IABP treatment did not result in a significant hemodynamic improvement compared with medical therapy alone in a randomized prospective trial in patients with CS following PCI. Therefore, the use and recommendation for IABP treatment in CS remain unclear.
Shock (Augusta, Ga.) 01/2012; 37(4):378-84. · 2.87 Impact Factor
ABSTRACT: The IABP-SHOCK-trial was a morbidity-based randomized controlled trial in patients with infarction-related cardiogenic shock (CS), which used the change of the quantified degree of multiorgan failure as determined by APACHE II score over a 4-day period as primary outcome measure. The prospective hypothesis was that adding IABP therapy to "standard care" would improve CS-triggered multi organ dysfunction syndrome (MODS). The primary endpoint showed no difference between conventionally managed cardiogenic shock patients and those with IABP support. In an inflammatory marker substudy, we analysed the prognostic value of interleukin (IL)-1β, -6, -7, -8, and -10 in patients with acute myocardial infarction complicated by cardiogenic shock.
Inflammatory marker substudy of the prospective, randomized, controlled, open label IABP-SHOCK-trial (Clinical-Trials-gov-ID-NCT00469248).
A single-center study was performed in a 12-bed Intensive-Care-Unit in an university hospital in which 40 consecutive patients were enrolled with an observational period of 96 h.
The pro- and anti-inflammatory markers IL-6, -7, -8 and -10 showed a predictive power for mortality of infarct-related CS patients, while IL-1β did not discriminate. The maximal values during the observational period, in case of IL-7 the minimal value, showed the best power to predict mortality. Both, ROC and multivariate analyses confirmed these suggestions (area under the curve: IL-8, 0.80 ± 0.08; IL-6, 0.79 ± 0.08; IL-10, 0.76 ± 0.08; IL-7, 0.69 ± 0.08). Inflammatory markers were not affected by the presence of IABP support.
The inflammatory response in patients with myocardial infarction complicated by cardiogenic shock, as reflected by the inflammatory markers IL-6, IL-7, IL-8 and IL-10, demonstrates a clinically relevant prognostic contribution to clinical outcome.
Clinical Research in Cardiology 01/2012; 101(5):375-84. · 2.95 Impact Factor
ABSTRACT: Bradycardia complicating percutaneous coronary intervention (PCI) can require temporary pacing. A transcoronary approach using the guidewire in the coronary artery may be a useful alternative to transvenous pacing. The purpose of the present study was to compare the efficacy of two different coronary guidewires in transcoronary pacing: a novel guidewire (VisionWire®, Biotronik, Germany) which has a coating to electrically insulate the shaft, thereby maximizing current delivery through the intracoronary section compared to a standard guidewire (without insulation) and a standard guidewire/balloon combination.
Unipolar transcoronary pacing was performed in 15 pigs under general anesthesia. In each animal, the new VisionWire was compared to a standard floppy guidewire and to a standard floppy guidewire loaded with a standard angioplasty balloon (which provides additional shaft insulation). The coronary guidewire was the cathode and a skin patch electrode (on the anterior or posterior chest wall) was the anode. We examined the effect of different electrode combinations on transcoronary pacing as assessed by threshold and impedance data and the magnitude of the epicardial electrocardiogram. Transcoronary pacing with the bare standard guidewire was effective in 77% of cases using an anterior skin patch electrode and in 87% with a posterior patch at pacing thresholds of 6.7 ± 2.9 V and 4.1 ± 3.0 V, respectively. Loading the same guidewire with an angioplasty balloon increased the pacing efficacy to 100% with significantly lower pacing thresholds of 2.4 ± 1.6 V with an anterior patch and 1.6 ± 1.3 V with a posterior patch (p < 0.001). The bare VisionWire yielded 100% pacing efficacy, with the lowest pacing thresholds of 1.6 ± 0.7 V and 1.0 ± 0.6 V anterior and posterior patch positions, respectively (p < 0.001). In all studies the pacing efficacy was higher and thresholds lower with the skin patch electrode on the posterior chest wall than on the anterior chest wall.
Transcoronary pacing in the animal model is an effective technique. The VisionWire, (even without the additional insulation of a balloon in place) performed better than a standard guidewire (with or without balloon use), and enabled 100% pacing efficacy at acceptable thresholds. Thus, transcoronary pacing, particularly with specific coronary guidewires may be a useful alternative to transvenous pacing during PCI, particularly in the emergency situation when unexpected bradycardias arise during transradial angioplasty when no central venous access is immediately available for transvenous pacing.
The Journal of invasive cardiology 03/2011; 23(3):108-14. · 1.84 Impact Factor
ABSTRACT: Intra-aortic balloon pump counterpulsation (IABP) is currently the most commonly used mechanical assist device for patients with cardiogenic shock due to acute myocardial infarction.Although there is only limited evidence by randomised controlled trials, the current guidelines of the American Heart Association/American College of Cardiology and the European Society of Cardiology strongly recommend the use of the intra-aortic balloon counterpulsation in patients with infarction-related cardiogenic shock on the basis of pathophysiological considerations as also non-randomised trials and registry data.
To determine the effect of IABP versus non-IABP or other assist devices guideline compliant standard therapy, in terms of efficacy and safety, on mortality and morbidity in patients with acute myocardial infarction complicated by cardiogenic shock.
Searches of CENTRAL, MEDLINE and EMBASE, LILACS, IndMed and KoreaMed, registers of ongoing trials and proceedings of conferences were conducted in January 2010, unrestricted by date. Reference lists were scanned and experts in the field contacted to obtain further information. No language restrictions were applied.
Randomised controlled trials on patients with myocardial infarction complicated by cardiogenic shock.
Data collection and analysis were performed according to a published protocol. Individual patient data were provided for five trials and merged with aggregate data. Summary statistics for the primary endpoints were hazard ratios (HR's) and odds ratios with 95% confidence intervals (CI).
Six eligible and two ongoing studies were identified from a total of 1410 references. Three compared IABP to standard treatment and three to percutaneous left assist devices (LVAD). Data from a total of 190 patients with acute myocardial infarction and cardiogenic shock were included in the meta-analysis: 105 patients were treated with IABP and 85 patients served as controls. 40 patients were treated without assisting devices and 45 patients with LVAD. HR's for all-cause 30-day mortality of 1.04 (95% CI 0.62 to 1.73) provides no evidence for a survival benefit. While differences in survival were comparable in patients treated with IABP, with and without LVAD, haemodynamics and incidences of device related complications show heterogeneous results.
Available evidence suggests that IABP may have a beneficial effect on the haemodynamics, however there is no convincing randomised data to support the use of IABP in infarct related cardiogenic shock.
Cochrane database of systematic reviews (Online) 01/2011; · 5.72 Impact Factor
Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2011; 57(14).
Critical care medicine 05/2010; 38(5):1390-1. · 6.37 Impact Factor
ABSTRACT: Intravenous abciximab reduces major adverse cardiac events in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Intracoronary abciximab bolus application during PCI results in high local drug concentration, improved perfusion, reduction of infarct size, and less microvascular obstruction. The hypothesis of this trial is that abciximab bolus intracoronary in comparison to standard intravenous application will improve the outcome of patients undergoing primary PCI in STEMI.
The Abciximab Intracoronary versus intravenously Drug Application in STEMI (AIDA STEMI) study is a 1,912-patient, prospective, multicenter, randomized, open-label, controlled trial. The study is designed to compare the efficacy and safety of intracoronary versus intravenous bolus abciximab administration during primary PCI with subsequent intravenous infusion for 12 hours. Patients will be randomized in a 1:1 fashion to 1 of the 2 treatments. The primary efficacy end point of AIDA STEMI is the composite of all-cause mortality, recurrent MI, or new congestive heart failure within 90 days of randomization. The primary safety outcome assessment will be major bleeding.
The AIDA STEMI study addresses important questions regarding the efficacy and safety of intracoronary abciximab bolus administration during primary PCI in patients with STEMI, potentially optimizing the route of administration of glycoprotein IIb/IIIa inhibitors in the catheterization laboratory.
American heart journal 04/2010; 159(4):547-54. · 4.65 Impact Factor
Critical care medicine 01/2010; 38(1):343-344. · 6.37 Impact Factor
ABSTRACT: Transcoronary pacing for the treatment of bradycardia during percutaneous coronary intervention (PCI) is not well established, but may be a useful technique in interventional cardiology. We developed a porcine model to examine the feasibility and efficacy of transcoronary pacing during PCI.
Eight pigs under general anesthesia underwent unipolar transcoronary pacing with a standard floppy guidewire in a coronary artery (as the cathode) and a skin patch electrode (as the anode). We examined the effect of skin-patch position (groin vs. anterior or posterior chest wall), the presence of an angioplasty balloon on the guidewire and also which coronary artery was "wired" on the efficacy of pacing as assessed by capture and threshold data. Pacing with the bare guidewire and a maximum output of 10 V was successful in 54% of the animals with a groin patch and the anterior chestwall patch, but in 100% with a posterior chest-wall patch. The pacing thresholds were 8.3 +/- 2.2 V, 7.6 +/- 2.8 V and 3.4 +/- 2.4 V with the patch in these sites, respectively. With an angioplasty balloon over the guidewire, pacing efficacy increased to 100% (irrespective of the target vessel or patch location) and pacing thresholds were significantly reduced (p < 0.05) to 2.7 +/- 1.5 (with a groin patch) and 1.0 +/- 0.7 V (with a posterior chestwall patch). With optimal pacing set-up (posterior chest-wall patch and angioplasty-balloon insulation), pacing thresholds were similar to those obtained with standard bipolar transvenous pacing at 1.2 +/- 0.8 V. We did not observe any adverse effects of coronary pacing. Skeletal muscle contraction was only generated at high-output levels.
This pig model examines the practicalities of transcoronary pacing and shows that this technique can produce 100% capture at thresholds comparable to the transvenous approach. This technique may have a role during PCI, particularly in an emergency situation.
The Journal of invasive cardiology 12/2009; 21(12):634-8. · 1.84 Impact Factor
ABSTRACT: Patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction with cardiogenic shock (CS) are often treated with intra-aortic balloon pump counterpulsation (IABP), even though the evidence to support this is limited. We determined whether IABP as an addition to PCI-centered therapy ameliorates multiorgan dysfunction syndrome (MODS) in patients with acute myocardial infarction complicated by CS.
A prospective, randomized, controlled, open-label clinical trial recruiting patients between March 2003 and June 2004 (ClinicalTrials.gov ID NCT00469248).
Tertiary care university hospital.
Forty-five consecutive patients with AMI and CS undergoing PCI were randomized to treatment with or without IABP.
Acute Physiology and Chronic Health Evaluation (APACHE) II scores (primary outcome measure), hemodynamic values, inflammatory markers, and plasma brain natriuretic peptide (BNP) levels (secondary outcomes) were collected over 4 days from randomization. The prospective hypothesis was that adding IABP therapy to "standard care" would improve CS-triggered MODS. The addition of IABP to standard therapy did not result in a significant improvement in MODS (measured by serial APACHE II scoring over 4 days). IABP use had no significant effect on cardiac index or systemic inflammatory activation, although BNP levels were significantly lower in IABP-treated patients. Initial and serial APACHE II scoring correlated with mortality better than cardiac index, systemic inflammatory state, and BNP levels in this group of patients. Nonsurvivors had significantly higher initial APACHE II scores (29.9 +/- 2.88) than survivors (18.1 +/- 1.66, p < .05). Nevertheless, discrepancies among patients within the groups cannot be ruled out and might interfere with our results.
In this randomized trial addressing addition of IABP in CS patients, mechanical support was associated only with modest effects on reduction of APACHE II score as a marker of severity of disease, improvement of cardiac index, reduction of inflammatory state, or reduction of BNP biomarker status compared with medical therapy alone. However, the limitations of our present trial preclude any definitive conclusion, but request for a larger prospective, randomized, multicentered trial with mortality as primary end point.
Critical care medicine 09/2009; 38(1):152-60. · 6.37 Impact Factor
ABSTRACT: Levosimendan improves left ventricular hemodynamic function in patients with cardiogenic shock. However, its impact on right ventricular performance has not been determined. We compared the hemodynamic effects of levosimendan on left and right ventricular function in patients with intractable cardiogenic shock following myocardial infarction.
Observational hemodynamic study.
Tertiary care center university hospital.
Fifty-six patients with cardiogenic shock secondary to myocardial infarction were treated with percutaneous revascularization (including intra-aortic balloon pump when appropriate) and commenced on conventional inotropic therapy.
Twenty-five consecutive patients with cardiogenic shock due to myocardial infarction who had not improved sufficiently with conventional therapy (including dobutamine and norepinephrine) received levosimendan (as a bolus of 12 microg/kg per minute for 10 mins then 0.1 microg/kg per minute--0.2 mug/kg per minute) as "bail-out" therapy for 24 hrs while invasive hemodynamic parameters were recorded.
Levosimendan therapy was associated with a significant increase in cardiac index from 2.1 +/- 0.1 to 3.0 +/- 0.2 L x min x m (p < .01). In addition, levosimendan enhanced right ventricular cardiac power index (0.14 +/- 0.19 to 0.18W +/- 0.12, p < .001), while pulmonary vascular resistance fell from 227.7 +/- 94.5 to 178.1 +/- 62.3 dyne x s x cm (p = .002). No significant change in central venous pressure or mean pulmonary artery pressure was observed. The observed hemodynamic improvement was sustained after the levosimendan infusion was stopped.
Levosimendan infusion for cardiogenic shock following acute myocardial infarction improved hemodynamic parameters of right ventricular performance. Furthermore, we describe the use of right ventricular cardiac power index as a hemodynamic parameter of right ventricular performance.
Critical care medicine 08/2009; 37(12):3017-23. · 6.37 Impact Factor
ABSTRACT: Stress-induced cardiomyopathy, also known as takotsubo syndrome, imitates an acute ST elevation myocardial infarction or an acute coronary syndrome, but without concomitant coronary artery disease. It mainly affects postmenopausal women, but no established epidemiologic data of this syndrome are available to date. Furthermore, the underlying etiologies are still largely unknown. The most frequently described trigger is strong emotional stress. Supportive therapy with aspirin, beta-blockers and angiotensin-converting enzyme inhibitors is recommended. The abnormal kinetics usually reverse or improve within 4-5 weeks. Compared with acute myocardial infarction, takotsubo cardiomyopathy carries a favorable prognosis. However, severe complications, including ventricular fibrillation and cardiogenic shock, may still occur.
Medizinische Klinik 07/2009; 104(6):434-40. · 0.34 Impact Factor
ABSTRACT: The multiple organ dysfunction syndrome (MODS) is the sequential failure of organ systems after a trigger event (e.g. cardiogenic shock) with a high mortality. ACE-inhibitors [ACEI] are known to ameliorate depressed autonomic function (heart rate variability [HRV]) to improve endothelial function and to decrease blood pressure. Modifications of these targets reduce major adverse cardiovascular events (patients with arterial hypertension, coronary artery disease and chronic heart failure). Our study aimed to characterize potential benefits of ACEI therapy in MODS patients.
178 score-defined consecutive patients were enrolled. Inclusion criterion was an APACHE II score >or=20 at admission to the ICU. Patients were evaluated for ACEI therapy and followed for 28, 180 and 365 days. HRV was calculated according to the international standards.
68 patients received an ACEI during their ICU stay whereas 110 did not. The 28-day mortality was 55% (no ACEI treatment) vs. 22% (ACEI treatment, p<0.0001) and the 1-year mortality accounted for 75% (no ACEI) vs. 50% (ACEI), p<0.0001. There was no significant survival difference between early and later application of ACEI (after day 4), both application modes were characterized by an improved survival. MODS patients with ACEI treatment at admission had a better preserved HRV.
Our results may suggest that MODS patients with ACEI treatment may have lower short- and longer-term mortality. HRV was less attenuated when patients received ACEI therapy at admission. Consequently, effectiveness of ACEI therapy should be validated in a prospective trial.
International journal of cardiology 01/2009; 140(3):296-303. · 7.08 Impact Factor
DMW - Deutsche Medizinische Wochenschrift 12/2008; 133(45):2341-2. · 0.53 Impact Factor