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The Journal of Emergency Medicine Mar 2022Left ventricular assist devices (LVADs) can be used as a bridging therapy for myocardial recovery or cardiac transplant, as well as a destination therapy for long-term... (Review)
Review
BACKGROUND
Left ventricular assist devices (LVADs) can be used as a bridging therapy for myocardial recovery or cardiac transplant, as well as a destination therapy for long-term support in patients with advanced heart failure. Patients with LVADs can present to the emergency department (ED) for acute deterioration and emergency physicians (EPs) must be equipped with the necessary knowledge and skill to treat this unique population.
OBJECTIVE
This review describes the role of point-of-care ultrasound (POCUS) in the evaluation of patients with LVADs and illustrates how EPs can incorporate POCUS into the evaluation of these patients in the ED.
DISCUSSION
The clinical applications for which POCUS may be useful in patients with LVADs include hypotension or shock, dyspnea, cardiac failure, dysrhythmia, syncope, and cardiac arrest. The normal features of POCUS in patients with LVADs and the features of POCUS associated with diseased states are presented.
CONCLUSIONS
Patients with LVADs have altered anatomy and physiology. Therefore, an understanding of key modifications to standard POCUS views is necessary so that EPs can use POCUS effectively in their evaluation of these patients.
Topics: Emergency Service, Hospital; Heart Failure; Heart-Assist Devices; Humans; Point-of-Care Systems; Ultrasonography
PubMed: 34991913
DOI: 10.1016/j.jemermed.2021.10.018 -
Biomedicine & Pharmacotherapy =... Jun 2023The broad-spectrum antineoplastic drug doxorubicin (DOX) has one of the most serious chronic side effects on the heart, dilated cardiomyopathy, but the precise molecular...
The broad-spectrum antineoplastic drug doxorubicin (DOX) has one of the most serious chronic side effects on the heart, dilated cardiomyopathy, but the precise molecular mechanisms underlying disease progression subsequent to long latency periods remain puzzling. Here, we established a model of DOX-induced dilated cardiomyopathy. In a cardiac cytology exploration, we found that differentially expressed genes in the KEGG signaling pathway enrichment provided a novel complex network of mTOR bridging autophagy and oxidative stress. Validation results showed that DOX caused intracellular reactive oxygen species accumulation in cardiomyocytes, disrupted mitochondria, led to imbalanced intracellular energy metabolism, and triggered cardiomyocyte apoptosis. Apoptosis showed a negative correlation with DOX-regulated cardiomyocyte autophagy. To evaluate whether the inhibition of mTOR could upregulate autophagy to protect cardiomyocytes, we used rapamycin to restore autophagy depressed by DOX. Rapamycin increased cardiomyocyte survival by easing the autophagic flux blocked by DOX. In addition, rapamycin reduced oxidative stress, prevented mitochondrial damage, and restored energy metabolic homeostasis in DOX-treated cardiomyocytes. In vivo, we used metformin (Met) which is an AMPK activator to protect cardiac tissue to alleviate DOX-induced dilated cardiomyopathy. In this study, Met significantly attenuated the oxidative stress response of myocardial tissue caused by DOX and activated cardiomyocyte autophagy to maintain cardiomyocyte energy metabolism and reduce cardiomyocyte apoptosis by downregulating mTOR activity. Overall, our study revealed the role of autophagy and apoptosis in DOX-induced dilated cardiomyopathy and demonstrated the potential role of regulation of the AMPK/mTOR axis in the treatment of DOX-induced dilated cardiomyopathy.
Topics: Humans; Cardiomyopathy, Dilated; AMP-Activated Protein Kinases; Doxorubicin; TOR Serine-Threonine Kinases; Myocytes, Cardiac; Apoptosis; Autophagy; Oxidative Stress; Sirolimus
PubMed: 37060659
DOI: 10.1016/j.biopha.2023.114691 -
EuroIntervention : Journal of EuroPCR... Jan 2021Angina and no obstructive coronary artery disease (ANOCA) is common. A potential cause of angina in this patient population is a myocardial bridge (MB). We aimed to...
AIMS
Angina and no obstructive coronary artery disease (ANOCA) is common. A potential cause of angina in this patient population is a myocardial bridge (MB). We aimed to study the anatomical and haemodynamic characteristics of an MB in patients with ANOCA.
METHODS AND RESULTS
Using intravascular ultrasound (IVUS), we identified 184 MBs in 154 patients. We evaluated MB length, arterial compression, and halo thickness. MB muscle index (MMI) was defined as MB length×halo thickness. Haemodynamic testing of the MB was performed using an intracoronary pressure/Doppler flow wire at rest and during dobutamine stress. We defined an abnormal diastolic fractional flow reserve (dFFR) as ≤0.76 during stress. The median MB length was 22.9 mm, arterial compression 30.9%, and halo thickness 0.5 mm. The median MMI was 12.1. Endothelial and microvascular dysfunction were present in 85.4% and 22.1%, respectively. At peak dobutamine stress, 94.2% of patients had a dFFR ≤0.76 within and/or distal to the MB. MMI was associated with an abnormal dFFR.
CONCLUSIONS
In select patients with ANOCA who have an MB by IVUS, the majority have evidence of a haemodynamically significant dFFR during dobutamine stress, suggesting the MB as being a cause of their angina. A comprehensive invasive assessment of such patients during coronary angiography provides important diagnostic information that can guide management.
Topics: Angina Pectoris; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Fractional Flow Reserve, Myocardial; Humans; Myocardial Bridging
PubMed: 33074153
DOI: 10.4244/EIJ-D-20-00779 -
International Journal of Molecular... Apr 2021Inherited cardiomyopathies are frequent causes of sudden cardiac death (SCD), especially in young patients. Despite at the autopsy they usually have distinctive... (Review)
Review
Inherited cardiomyopathies are frequent causes of sudden cardiac death (SCD), especially in young patients. Despite at the autopsy they usually have distinctive microscopic and/or macroscopic diagnostic features, their phenotypes may be mild or ambiguous, possibly leading to misdiagnoses or missed diagnoses. In this review, the main differential diagnoses of hypertrophic cardiomyopathy (e.g., athlete's heart, idiopathic left ventricular hypertrophy), arrhythmogenic cardiomyopathy (e.g., adipositas cordis, myocarditis) and dilated cardiomyopathy (e.g., acquired forms of dilated cardiomyopathy, left ventricular noncompaction) are discussed. Moreover, the diagnostic issues in SCD victims affected by phenotype-negative hypertrophic cardiomyopathy and the relationship between myocardial bridging and hypertrophic cardiomyopathy are analyzed. Finally, the applications/limits of virtopsy and post-mortem genetic testing in this field are discussed, with particular attention to the issues related to the assessment of the significance of the genetic variants.
Topics: Biopsy; Cardiomyopathies; Death, Sudden, Cardiac; Diagnostic Errors; Forensic Medicine; Genetic Testing; Humans
PubMed: 33923560
DOI: 10.3390/ijms22084124 -
Circulation Research Feb 2020RNA modulation has become a promising therapeutic approach for the treatment of several types of disease. The emerging field of noncoding RNA-based therapies has now... (Review)
Review
RNA modulation has become a promising therapeutic approach for the treatment of several types of disease. The emerging field of noncoding RNA-based therapies has now come to the attention of cardiovascular research, in which it could provide valuable advancements in comparison to current pharmacotherapy such as small molecule drugs or antibodies. In this review, we focus on noncoding RNA-based studies conducted mainly in large-animal models, including pigs, rabbits, dogs, and nonhuman primates. The obstacles and promises of targeting long noncoding RNAs and circRNAs as therapeutic modalities in humans are specifically discussed. We also describe novel ex vivo methods based on human cells and tissues, such as engineered heart tissues and living myocardial slices that could help bridging the gap between in vivo models and clinical applications in the future. Finally, we summarize antisense oligonucleotide drugs that have already been approved by the Food and Drug Administration for targeting mRNAs and discuss the progress of noncoding RNA-based drugs in clinical trials. Additional factors, such as drug chemistry, drug formulations, different routes of administration, and the advantages of RNA-based drugs, are also included in the present review. Recently, first therapeutic miRNA-based inhibitory strategies have been tested in heart failure patients as well as healthy volunteers to study effects on wound healing (NCT04045405; NCT03603431). In summary, a combination of novel therapeutic RNA targets, large-animal models, ex vivo studies with human cells/tissues, and new delivery techniques will likely lead to significant progress in the development of noncoding RNA-based next-generation therapeutics for cardiovascular disease.
Topics: Animals; Cardiovascular Diseases; Clinical Trials as Topic; Humans; RNAi Therapeutics; Translational Research, Biomedical
PubMed: 32105576
DOI: 10.1161/CIRCRESAHA.119.315856 -
Interactive Cardiovascular and Thoracic... Jul 2022In patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known... (Review)
Review
OBJECTIVES
In patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known to yield better outcomes than emergency surgery. We aimed to investigate the effectiveness of Impella (Abiomed, Danvers, MA, USA) as a bridge to cardiac surgery in patients with cardiogenic shock.
METHODS
We reviewed 7 patients with cardiogenic shock who underwent Impella support as a bridge to cardiac surgery using cardiopulmonary bypass at our institution between April 2018 and August 2021.
RESULTS
Cardiogenic shock was caused by ventricular septal rupture in 3 patients, papillary muscle rupture in 1 and acute myocardial infarction in 3. Cardiac surgery was delayed by 1-7 (3.9 ± 2.5) days with Impella support after the diagnosis of cardiogenic shock, during which the hepatic and renal function of the patients improved significantly. Device-related or operation-related adverse events included re-exploration for bleeding in 3 patients, acute limb ischaemia due to thromboembolism in 1 and intraoperative aortic dissection in 1. Thirty-day mortality was 14.3%, and the cumulative survival was 71.4% at 1 year. The survival tended to be better than that in historical control group in which extracorporeal membrane oxygenation was used as a bridge to surgery (P = 0.0992).
CONCLUSIONS
Impella is an effective tool for bridging patients with cardiogenic shock to surgery. This strategy may improve surgical outcomes in patients with cardiogenic shock. However, prolonged Impella support may increase significant adverse events, and further investigation is required to determine the optimal duration of support before surgery.
Topics: Cardiac Surgical Procedures; Extracorporeal Membrane Oxygenation; Heart-Assist Devices; Humans; Retrospective Studies; Shock, Cardiogenic; Treatment Outcome
PubMed: 35373286
DOI: 10.1093/icvts/ivac088 -
Clinical Therapeutics Mar 2023The optimal perioperative antithrombosis management for carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) hybrid surgeries remains unclear;...
PURPOSE
The optimal perioperative antithrombosis management for carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) hybrid surgeries remains unclear; however, a more aggressive antithrombotic therapy might be required after a hybrid CAS + CABG duo stent-related intimal injury or the use of protamine-neutralizing heparin. This study evaluated the safety and efficacy of tirofiban as a bridging therapy after a hybrid CAS + CABG surgery.
METHODS
Between June 2018 and February 2022, a total of 45 patients undergoing a hybrid CAS + off-pump CABG surgery were divided into either the control group (standard dual antiplatelet therapy postsurgery, n = 27) or the tirofiban group (tirofiban bridging + dual antiplatelet therapy, n = 18). The 30-day outcome was compared between the 2 groups, and the primary end points included stroke, postoperative myocardial infarction, and death.
FINDINGS
Two patients (7.41%) from the control group experienced a stroke. There was a trend toward a lower rate of composite end points, including stroke, postoperative myocardial infarction, and death, within the tirofiban group that did not reach statistical significance (0% vs 11.1%; P = 0.264). The need for a transfusion was similar between the 2 groups (33.33% vs 29.63%; P = 0.793). There were no major bleeding events in the 2 groups.
IMPLICATIONS
Tirofiban bridging therapy was safe, with a trend toward reducing the risk of ischemic events after a hybrid CAS + off-pump CABG surgery. Tirofiban might be a feasible periprocedural bridging protocol in high-risk patients.
Topics: Humans; Tirofiban; Coronary Artery Disease; Platelet Aggregation Inhibitors; Carotid Stenosis; Stents; Myocardial Infarction; Coronary Artery Bypass; Stroke; Postoperative Complications; Carotid Arteries; Treatment Outcome
PubMed: 36801114
DOI: 10.1016/j.clinthera.2023.01.012 -
Pharmaceutics May 2024This review paper examines the evolution of photodynamic therapy (PDT) as a novel, minimally invasive strategy for treating atherosclerosis, a leading global health... (Review)
Review
This review paper examines the evolution of photodynamic therapy (PDT) as a novel, minimally invasive strategy for treating atherosclerosis, a leading global health concern. Atherosclerosis is characterized by the accumulation of lipids and inflammation within arterial walls, leading to significant morbidity and mortality through cardiovascular diseases such as myocardial infarction and stroke. Traditional therapeutic approaches have primarily focused on modulating risk factors such as hypertension and hyperlipidemia, with emerging evidence highlighting the pivotal role of inflammation. PDT, leveraging a photosensitizer, specific-wavelength light, and oxygen, offers targeted treatment by inducing cell death in diseased tissues while sparing healthy ones. This specificity, combined with advancements in nanoparticle technology for improved delivery, positions PDT as a promising alternative to traditional interventions. The review explores the mechanistic basis of PDT, its efficacy in preclinical studies, and the potential for enhancing plaque stability and reducing macrophage density within plaques. It also addresses the need for further research to optimize treatment parameters, mitigate adverse effects, and validate long-term outcomes. By detailing past developments, current progress, and future directions, this paper aims to highlight PDT's potential in revolutionizing atherosclerosis treatment, bridging the gap from experimental research to clinical application.
PubMed: 38931851
DOI: 10.3390/pharmaceutics16060729 -
The Annals of Thoracic Surgery Jun 2020
Topics: Coronary Angiography; Coronary Vessel Anomalies; Humans; Myocardial Bridging
PubMed: 31706871
DOI: 10.1016/j.athoracsur.2019.09.051 -
BMC Medicine Apr 2024Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12... (Randomized Controlled Trial)
Randomized Controlled Trial
Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial.
BACKGROUND
Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy.
METHODS
Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding.
RESULTS
Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 10/L were independent predictors of minor bleeding events.
CONCLUSIONS
This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH.
TRIAL REGISTRATION
ISRCTN65203415.
Topics: Humans; Male; Female; Aged; Stents; Aged, 80 and over; Anticoagulants; Platelet Aggregation Inhibitors; Heparin, Low-Molecular-Weight; Dalteparin; Treatment Outcome; Surgical Procedures, Operative; Hemorrhage; Placebos; Perioperative Care
PubMed: 38649992
DOI: 10.1186/s12916-024-03391-2