RESUMEN
Heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) is a severe complication of heparin caused by an antibody response to the heparin-platelet factor 4 complex which results in severe thrombosis. Heparin rechallenge in HITTS patients carries a high risk of inducing thrombosis. Antithrombin agents represent treatment alternatives in HITTS patients who require anticoagulation. We report successful coronary stent implantation in a HITTS patient using the antithrombin agent argatroban.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Enfermedad Coronaria/terapia , Heparina/efectos adversos , Infarto del Miocardio/terapia , Ácidos Pipecólicos/administración & dosificación , Inhibidores de Agregación Plaquetaria/administración & dosificación , Stents , Trombocitopenia/inducido químicamente , Trombosis/inducido químicamente , Anciano , Arginina/análogos & derivados , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Femenino , Heparina/administración & dosificación , Humanos , Infarto del Miocardio/diagnóstico por imagen , Sulfonamidas , SíndromeRESUMEN
STUDY OBJECTIVE: To determine the angiographic patency of cryopreserved saphenous vein grafts used as conduits during coronary artery bypass surgery and whether this is affected by postoperative immunosuppressive therapy. DESIGN AND SETTING: A retrospective review of medical records and coronary angiograms of patients at a university hospital. PATIENTS: Eleven patients undergoing 12 coronary artery bypass operations during which a total of 26 distal coronary anastomoses were created using cryopreserved vein grafts. MEASUREMENTS: Eight postoperative coronary angiograms were performed in 10 patients surviving longer than 1 week. All angiograms were performed on the basis of symptoms of suspected myocardial ischemia. Angiographic results, postoperative anticoagulation, and therapy with immunosuppressive agents were analyzed. RESULTS: Seventeen cryopreserved vein grafts were studied; one (6%) was patent, 12 (71%) were occluded, and 4 (23%) were stenosed. In patients treated with azathioprine, seven of the eight cryopreserved vein grafts were occluded. In patients not receiving immunosuppression, five were occluded, three were stenosed, and one was patent. All internal mammary grafts were widely patent. CONCLUSION: Cryopreserved vein grafts have a poor angiographic patency which did not appear to be affected by immunosuppressive therapy with azathioprine. The use of this graft should be restricted and alternative arterial conduits utilized.
Asunto(s)
Puente de Arteria Coronaria/métodos , Criopreservación , Oclusión de Injerto Vascular/diagnóstico por imagen , Vena Safena , Anciano , Azatioprina/uso terapéutico , Angiografía Coronaria , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/epidemiología , Oclusión de Injerto Vascular/etiología , Humanos , Inmunosupresores/uso terapéutico , Masculino , Cuidados Posoperatorios , Estudios Retrospectivos , Vena Safena/fisiología , Vena Safena/trasplante , Factores de Tiempo , Grado de Desobstrucción Vascular/efectos de los fármacos , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
We describe a double-balloon technique for performing a percutaneous balloon pericardiotomy. This technique was employed when the large, single dilation balloon customarily used for this procedure failed to fully inflate across the parietal pericardium. Two smaller balloons were advanced through the same skin tract and simultaneously inflated, thus producing an adequate pericardial window. This double-balloon technique allowed for the more secure anchoring of the balloons across the pericardium and for the delivery of greater dilation pressures.
Asunto(s)
Cateterismo/instrumentación , Derrame Pericárdico/terapia , Técnicas de Ventana Pericárdica/instrumentación , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/terapia , Adulto , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/terapia , Carcinoma Ductal de Mama/diagnóstico por imagen , Carcinoma Ductal de Mama/terapia , Femenino , Humanos , Masculino , Neoplasias Primarias Desconocidas/diagnóstico por imagen , Neoplasias Primarias Desconocidas/terapia , Derrame Pericárdico/diagnóstico por imagen , Derrame Pleural Maligno/diagnóstico por imagen , Derrame Pleural Maligno/terapia , RadiografíaRESUMEN
The contribution of the autonomic nervous system, angiotensin II (ANG II), and arginine vasopressin (AVP) to the control of blood pressure (BP) was examined in 12 chronically instrumented tethered monkeys. The vasopressin antagonist, [d(CH2)5AVP] (Manning Compound, MC), the ANG II antagonist, saralasin (SAR), and the ganglionic blocking drug, hexamethonium (Hx), were injected in a random sequence into the left atrium (LA) while BP and heart rate (HR) were monitored. When given as the first antagonist, MC caused a slight decrease in BP; SAR did not significantly decrease BP regardless of the sequence of administration, whereas Hx caused a consistent decrease in blood pressure of 35-50 mmHg. Seven (4 intact and 3 with renal denervation) additional animals were involved in hemorrhage experiments. Blood pressure was reduced to 50-60 mmHg by hemorrhage and then allowed to return spontaneously. Ten to 15 min after the end of the hemorrhage, MC was given. When blood pressure had stabilized, SAR was given. Blood pressure returned to 80-90 mmHg after the hemorrhage. MC did not affect the blood pressure recovery; however, saralasin reduced it to the post-hemorrhage levels. We would conclude that the sympathetic nervous system is the primary controlling mechanism for BP in the conscious primate, with AVP making a minor contribution. The release of renin would appear to be primarily under the control of the sympathetic nervous system.
Asunto(s)
Arginina Vasopresina/fisiología , Sistema Nervioso Autónomo/fisiología , Presión Sanguínea/fisiología , Sistema Renina-Angiotensina/fisiología , Animales , Antihipertensivos/farmacología , Arginina Vasopresina/análogos & derivados , Arginina Vasopresina/farmacología , Desnervación , Femenino , Hemorragia/fisiopatología , Hexametonio , Compuestos de Hexametonio/farmacología , Riñón/inervación , Macaca mulatta , Masculino , Saralasina/farmacologíaRESUMEN
The pathogenesis of the hemodynamic abnormalities of diabetic ketoacidosis (DKA) is not well understood. Previous studies suggest that prostacyclin (PGI2) production by adipose tissue is increased in DKA. We investigated the role of PGI2 in the pathogenesis of the reduced vascular resistance in DKA. Rats with streptozocin-induced DKA were anesthetized with pentobarbital sodium, and flow was measured with an electromagnetic probe on the infradiaphragmatic aorta. The plasma level of 6-keto-PGF1 alpha (stable derivative of PGI2) was higher (mean +/- SE 0.91 +/- 0.05 ng/ml) and vascular resistance lower (4.9 +/- 0.2 mmHg.ml-1.min-1.100 g-1 [resistance units, RU]) in 67 rats with DKA than in 21 normal rats (0.34 +/- 0.03 ng/ml, P less than .01, and 9.0 +/- 0.7 RU, P less than .01, respectively). Inhibition of cyclooxygenase activity with either indomethacin or meclofenamic acid reduced the plasma 6-keto-PGF1 alpha level but failed to raise vascular resistance. Infusions of PGI2 in rats with DKA demonstrated that the vasculature was responsive to PGI2. Inhibition of cyclooxygenase activity not only reduced PGI2 production but also suppressed renin release. When the effects of the renin-angiotensin system were excluded by bilateral nephrectomy, indomethacin caused a significant increase (P less than .05) in vascular resistance. Thus, the failure of cyclooxygenase inhibitors to raise vascular resistance in DKA was a result of concurrent suppression of vasodilator (PGI2) and vasoconstrictor (renin-angiotensin system) mechanisms that are activated in DKA. Insulin administration increased vascular resistance (P less than .01) and decreased the level of plasma 6-keto-PGF1 alpha (P less than .01). Combined administration of PGI2 and insulin did not alter vascular resistance, suggesting that the increase in vascular resistance with insulin was predominantly due to the reduction of circulating PGI2. Thus, vascular resistance is decreased in DKA primarily as a result of the vasodilator effects of PGI2 produced by adipose tissue. The activation of the renin-angiotensin system represents a partial compensation. The increase in PGI2 production may contribute to the hypotension and mortality of DKA.
Asunto(s)
6-Cetoprostaglandina F1 alfa/sangre , Diabetes Mellitus Experimental/fisiopatología , Cetoacidosis Diabética/fisiopatología , Epoprostenol/farmacología , Hemodinámica , Animales , Glucemia/metabolismo , Presión Sanguínea/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Indometacina/farmacología , Insulina/farmacología , Masculino , Ácido Meclofenámico/farmacología , Nefrectomía , Ratas , Ratas Endogámicas , Valores de Referencia , Resistencia Vascular/efectos de los fármacosRESUMEN
To determine how well a seven-day interview-administered activity recall used in a large epidemiologic study at Stanford University reflected seven days of self-reported activity and directly measured physical activity, 30 white males, mean age 52 years, recorded daily physical activity for a week, and half of these wore an ambulatory solid-state minicomputer (Vitalog) which measures continuous heart rate and motion. Total hours of moderate, hard, and hard plus very hard activity were not significantly different for weekdays and weekends for self-report and recall and were significantly correlated. Total energy expenditure for subjects wearing the Vitalog averaged 38.5 +/- 6.7 kcal/kg/day compared to an average of 37.7 +/- 4.5 kcal/kg/day for recall or 39.6 +/- 7.2 kcal/kg/day for self-report. Conditioning activities are best remembered followed by home or leisure and job activities. Mean hours of sleep per week night were significantly greater reported by self-report than reported by recall, but the two were significantly correlated. It is concluded that a seven-day activity recall accurately reflects mean kcal/day expenditure, with conditioning activities being the best recalled. A self-report log used in conjunction with an interview-based seven-day recall might maximize accuracy of recall.