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Charanjit S Rihal

Publications and source records attributed to Charanjit S Rihal.

At least 19 recordsLinked to original sources
PubMed2007

Initial experience with the Cardiva Boomerang vascular closure device in diagnostic catheterization.

OBJECTIVES: The authors studied the safety and efficacy of the Cardiva Boomerang vascular closure device in patients undergoing diagnostic cardiac catheterization. BACKGROUND: Conventional vascular closure devices (sutures, collagen plugs, or metal clips) have been associated with catastrophic complications including arterial occlusion and foreign body infections; furthermore, they cannot be utilized in patients with peripheral vascular disease or vascular access site in a vessel other than the common femoral artery. The Cardiva Boomerang device facilitates vascular hemostasis without leaving any foreign body behind at the access site, can be used in peripheral vascular disease, and can be used in vessels other than the common femoral artery METHODS: A total of 96 patients undergoing transfemoral diagnostic cardiac catheterization were included in this study, including 25 (26%) patients with contraindications to conventional closure devices. Femoral angiography was performed prior to deployment of the Cardiva Boomerang closure device. Patients were ambulated at 1 hr after hemostasis was achieved. RESULTS: The device was successfully deployed and hemostasis achieved with the device alone in 95 (99%) patients. The device failed to deploy in 1 (1%) patient and required conversion to standard manual compression. Minor complications were observed in 5 (5%) patients. No patients experienced major complications including femoral hematoma > 4 cm, red blood cell transfusion, retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm, infection, arterial occlusion, or vascular surgery. CONCLUSIONS: The Cardiva Boomerang device is safe and effective in patients undergoing diagnostic cardiac catheterization using the transfemoral approach, facilitating early ambulation with low rates of vascular complications.

Cardiac Catheterization↗
PubMed2006

Association of angiotensin-converting enzyme inhibitors and serum lipids with plaque regression in cardiac allograft vasculopathy.

We assessed clinical predictors of the process of cardiac allograft vasculopathy (CAV) in 39 consecutive patients (mean 49 years old) using three-dimensional intravascular ultrasound (3-D IVUS) examination of the left anterior descending coronary artery at 36 +/- 38 months and 47 +/- 40 months after cardiac allotransplantation (TX). Compared with 17 patients with plaque progression, 22 patients with plaque regression were more likely to be male (P < .01), to have a higher use of angiotensin-converting enzyme inhibitors (ACEI, P < .05), and to have a lower volumetric remodeling index (P < .001). The changes in plaque volume correlated with the changes in total cholesterol (P < .005) and low-density lipoprotein cholesterol (P < .02). Plaque progression of CAV was independently associated with time after TX, hypertension, nonuse of ACEI, donor age, and changes in total cholesterol and triglycerides. In conclusion, plaque progression is associated with positive vascular remodeling and plaque regression is associated with lower serum lipids and ACEI in patients after TX.

Adult↗
PubMed2006

Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction.

OBJECTIVE: The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes. SUBJECTS AND METHODS: Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion. RESULTS: All patients with TLVABS were women (mean age, 72.0 +/- 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V2 of less than 1.75 mm and ST-segment elevation in lead V3 of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 x ST-elevation lead V2) + (ST-elevation V3) + (2 x ST-elevation V5) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003). CONCLUSIONS: Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.

Aged↗
PubMed2006

Long-term survival after right ventricular infarction.

Right ventricular myocardial infarction (RVMI) is associated with substantial in-hospital and first-year mortality, but few published studies have documented late survival to 5 to 10 years after infarction. We retrospectively identified 69 consecutive patients from Olmsted County, Minnesota, with new RVMI diagnosed between January 1, 1988 and January 1, 1998, in whom coronary angiography was performed soon after admission. Long-term follow-up status was determined for all patients. RVMI secondary to isolated right coronary artery (RCA) disease had a 10-year actuarial survival of 62%, versus 52% for those with combined RCA and left coronary artery (LCA) disease (p = 0.21). Mortality within the first year after infarction was substantial for all patients with RVMI; however, there was a nonsignificant trend for patients with RCA disease (18%) versus those with RCA and LCA disease (27%; p = 0.21). Annual actuarial risks of death beyond the first year to 10 years after infarction were 2% per year for RCA disease and 3% for combined RCA and LCA disease. Patients with combined LCA and RCA disease were older (p = 0.01) but otherwise similar in baseline characteristics to patients with RCA disease. Occurrence of congestive heart failure, atrial fibrillation, and mechanical complications was similar in the 2 groups. In conclusion, RVMI is associated with substantial first-year mortality, which decreases to a much lower attrition rate between years 1 and 10, with no greater long-term mortality in those patients with concomitant LCA disease.

Aged↗
PubMed2006

Isolated elevation in troponin T after percutaneous coronary intervention is associated with higher long-term mortality.

OBJECTIVES: The aim of this study was to evaluate whether, in patients with normal post-procedure CK-MB, an isolated elevation in cardiac troponin T (cTnT) predicts long-term survival. BACKGROUND: Cardiac troponin T is a sensitive and specific marker of myonecrosis. There is little known about the incidence and prognostic significance of an isolated elevation of cTnT without a rise in creatine kinase (CK)-MB following PCI. METHODS: We evaluated the outcomes of 1,949 patients from the Mayo Clinic registry who had normal pre-procedure cTnT and CK-MB, required nonemergency percutaneous coronary intervention (PCI), and had normal CK-MB after the procedure. RESULTS: An elevation in cTnT (cTnT+) was observed in 383 patients (19.6%) (median 0.04 ng/ml, interquartile range 0.03 to 0.06 ng/ml). The TnT+ status was associated with adverse clinical and angiographic characteristics, and multivessel PCI. Over the median follow-up duration of 26 months, mortality (p < 0.001) and the combined rate of death and myocardial infarction (p = 0.004) were significantly higher in cTnT+ patients. Estimated 3-year survival for those with and without cTnT elevation was 86.9% and 93.2%, respectively. By multivariate analysis, an elevation in cTnT after PCI was an independent predictor of increased long-term mortality. A doubling in the post-PCI cTnT was associated with a partial hazard ratio of 1.20 (95% confidence interval 1.02 to 1.40; p = 0.023). CONCLUSIONS: An isolated minor elevation in cTnT after PCI provides long-term prognostic information regarding mortality and myocardial infarction.

Aged↗
PubMed2006

Narrative review: reperfusion strategies for ST-segment elevation myocardial infarction.

Optimal treatment for ST-segment elevation myocardial infarction depends on early diagnosis and rapid selection of the appropriate reperfusion strategy. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy at PCI-capable hospitals. For hospitals without PCI capability, there are 2 reperfusion strategies, primary PCI and thrombolytic therapy, which are both supported by clinical evidence and national guidelines. Transferring patients for primary PCI may cause delays and requires established, proven protocols, systems, and networks to achieve minimal door-to-balloon times. The authors review the available data and present a systematic, evidence-based approach in a simple framework to enable noncardiovascular and cardiovascular physicians to select the optimal reperfusion strategy. The framework is based on available data from clinical trials and local circumstances from clinical practice by incorporating duration of symptoms (fixed ischemia time) and anticipated transport delays to a PCI-capable facility (incurred ischemia time).

Aged↗
PubMed2006

Individual measurement and significance of carotid intima, media, and intima-media thickness by B-mode ultrasonographic image processing.

OBJECTIVE: We assessed the clinical significance of intima (IT), media (MT), and intima-media (IMT) thickness of the common carotid artery using B-mode ultrasonographic image processing. METHODS AND RESULTS: One hundred seventy consecutive patients underwent common carotid artery scanning using high-resolution ultrasonography. A total of 150 patients could be analyzed off-line using ultrasonographic image processing, devised for individual measurement of IT, MT, and IMT. By univariate analysis, IT (range, 0.27 to 0.41 mm) was associated with age, whereas MT (range, 0.27 to 0.74 mm) and IMT (range, 0.49 to 1.12 mm) were associated with age, fibrinogen, and creatinine. Among atherosclerosis risk factors, hypertension was associated with thickness of all 3 layers, whereas smoking was associated with IT only. By multivariate analysis, IT was associated with age, hypertension, and smoking, whereas MT and IMT were associated with age, hypertension, and blood urea nitrogen level. CONCLUSIONS: Carotid IT is associated with smoking, whereas age and hypertension are associated with thickness of all 3 arterial layers. Our results suggest a differential response of the vasculature to systemic risk factors.

Aged↗
PubMed2006

Relation of preprocedural statin therapy to in-hospital procedural complications following percutaneous coronary interventions in patients with hyperlipidemia.

We investigated whether the observed protective effect of hyperlipidemia is stronger in patients who take statins and, if so, whether that effect is likely due to patient characteristics associated with statin use. In-hospital complications and long-term outcomes of patients with hyperlipidemia (cholesterol level > or = 240 mg/dl) undergoing percutaneous coronary interventions (PCI) on statins (group Ia, n = 2,052) and not on statins (group Ib, n = 1,650) were compared with 726 patients with lower cholesterol levels (group II). Despite a higher prevalence of co-morbidities and worse angiographic characteristics in patients with hyperlipidemia, patients in group Ia had significantly lower in-hospital mortality (0% vs 2% in the other 2 groups, p < 0.001), a lower increase in the postprocedure creatine kinase-MB fraction (14% vs 27% in group Ib and 28% in group II, p < 0.001), and fewer PCI complications (15% vs 30% in groups Ib and II, p < 0.001). After adjustment, patients in group Ia had a significant decrease in complications (odds ratio 0.72, 95% confidence interval 0.65 to 0.92, p = 0.009). In contrast, those in group Ib had outcomes similar to those of patients with lower cholesterol. After application of propensity analysis to adjust for the likelihood of receiving statins based on clinical, angiographic, and procedural characteristics, group Ia had fewer in-hospital complications (odds ratio 0.75, 95% confidence interval 0.62 to 0.90, p = 0.002) and lower in-hospital mortality (odds ratio 0.32, 95% confidence interval 0.12 to 0.84, p = 0.021). After successful PCI, overall survival after dismissal and survival free of myocardial infarction and target vessel revascularization were similar. In conclusion, hyperlipidemia per se is not associated with lower in-hospital complications after PCI. The benefit is largely limited to patients on statin treatment.

Aged↗
PubMed2006

Association of obesity with left ventricular remodeling and diastolic dysfunction in patients without coronary artery disease.

Obese patients frequently complain of dyspnea. Deconditioning and altered left ventricular (LV) systolic or diastolic function with elevated filling pressures may contribute to dyspnea. This study analyzed 4,281 patients who underwent diagnostic coronary angiography from January 1, 1995, to December 31, 2000. No patients had coronary artery stenoses >50% of the luminal diameter, and all underwent echocardiography within the same 6-year period. The association between body mass index (BMI) and LV structure and systolic and diastolic function was examined. All analyses controlled for age and gender, with the effect size for BMI expressed using a standardized coefficient (SC). A higher BMI was associated with greater LV mass (SC 0.18, p <0.001), wall thickness (SC 0.17, p <0.001), and end-diastolic diameter (SC 0.07, p <0.001). Stroke volume increased with a higher BMI (SC 0.12, p = 0.001), but there was no association between BMI and the ejection fraction (SC 0.003, p = 0.81). Hemodynamic data from invasive studies showed an association between a higher BMI and increased LV end-diastolic pressure (mean 17 mm Hg for BMI <25 kg/m(2) vs 24 mm Hg for BMI >or=40 kg/m(2); SC 0.18, p <0.001), which persisted after controlling for end-diastolic volume (SC 0.22, p <0.001). Obesity was associated with ventricular remodeling, which may normalize wall stress while increasing stroke volume to match metabolic demand. Obesity was not associated with decreased systolic function. However, obesity was associated with increased LV end-diastolic pressure, which suggests an association between obesity and diastolic dysfunction. In conclusion, ventricular remodeling, LV diastolic dysfunction, and elevated filling pressures may contribute to the prevalence of heart failure in obese patients.

Blood Pressure↗
PubMed2006

A total of 1,007 percutaneous coronary interventions without onsite cardiac surgery: acute and long-term outcomes.

OBJECTIVES: We sought to compare clinical outcomes of elective percutaneous coronary intervention (PCI) and primary PCI for ST-segment elevation myocardial infarction (STEMI) at a community hospital without onsite cardiac surgery to those at a tertiary center with onsite cardiac surgery. BACKGROUND: Disagreement exists about whether hospitals with cardiac catheterization laboratories, but without onsite cardiac surgery, should develop PCI programs. Primary PCI for STEMI at hospitals without onsite cardiac surgery have achieved satisfactory outcomes; however, elective PCI outcomes are not well defined. METHODS: A total of 1,007 elective PCI and primary PCI procedures performed from March 1999 to August 2005 at the Immanuel St. Joseph's Hospital-Mayo Health System (ISJ) in Mankato, Minnesota, were matched one-to-one with those performed at St. Mary's Hospital (SMH) in Rochester, Minnesota. Strict protocols were followed for case selection and PCI program requirements. Clinical outcomes (in-hospital procedural success, death, any myocardial infarction, Q-wave myocardial infarction, and emergency coronary artery bypass surgery) and follow-up survival were compared between groups. RESULTS: Among 722 elective PCIs, procedural success was 97% at ISJ compared with 95% at SMH (p = 0.046). Among 285 primary PCIs for STEMI, procedural success was 93% at ISJ and 96% at SMH (p = 0.085). No patients at ISJ undergoing PCI required emergent transfer for cardiac surgery. Survival at two years' follow-up by treatment location was similar for patients with elective PCI and primary PCI. CONCLUSIONS: Similar clinical outcomes for elective PCI and primary PCI were achieved at a community hospital without onsite cardiac surgery compared with those at a tertiary center with onsite cardiac surgery using a prospective, rigorous protocol for case selection and PCI program requirements.

Aged↗
PubMed2006

Myocardial perfusion in apical ballooning syndrome correlate of myocardial injury.

BACKGROUND: The pathophysiology of the apical ballooning syndrome (ABS) is poorly understood. This study evaluated myocardial perfusion abnormalities at the time of presentation in patients with ABS and examined whether abnormal microvascular blood flow predicts the extent of myocardial injury. METHODS: We evaluated 42 consecutive patients, all women, with a diagnosis of ABS and technically adequate angiograms for the assessment of the TIMI myocardial perfusion grade (TMPG), an index of myocardial perfusion. RESULTS: Abnormal myocardial perfusion was present in 29 (69%) patients. There were no differences in age, frequency of conventional coronary atherosclerosis risk factors, left ventricular ejection fraction at either presentation or follow-up, congestive heart failure at presentation, or length of hospital stay between patients with normal versus those with abnormal TMPG. Patients with abnormal TMPG had higher peak troponin level compared with patients with normal TMPG (0.84 +/- 0.68 vs 0.42 +/- 0.33 ng/mL, P = .047). Similarly, ST elevation or deep T-wave inversion on the electrocardiogram was more common in patients with abnormal perfusion (86% vs 46%, P = .006). CONCLUSION: Impaired myocardial perfusion due to abnormal microvascular blood flow is frequently present in patients with ABS and correlates with the extent of myocardial injury. Microvascular dysfunction likely play a pivotal role in the pathogenesis of myocardial stunning in ABS.

Adult↗
PubMed2006

Plasma 8-iso-prostaglandin F2alpha, a marker of oxidative stress, is increased in patients with acute myocardial infarction.

BACKGROUND: Oxidative stress has been implicated in the pathogenesis of atherogenesis. The aim of our study is to examine whether the plasma 8-iso-prostaglandin F(2alpha) level, a marker of oxidative stress, is elevated in patients with acute myocardial infarction. METHODS: Three groups of patients were enrolled: (1) patients with no or minimal coronary artery disease (CAD) (n = 15); (2) patients with stable CAD (n = 31); (3) patients with acute myocardial infarction (n = 13). RESULTS: Plasma 8-iso-prostaglandin F(2alpha) levels were significantly elevated (p < 0.001) in patients with acute myocardial infarction (290.7 +/- 73.9 pg/ml) as compared to patients with stable CAD (182.0+75.7 pg/ml) and patients with no significant CAD (118.9 +/- 85.5 pg/ml). This remained significant after correcting for coronary atherosclerosis risk factors, age, extent of atherosclerosis, and C-reactive protein (CRP) level. CONCLUSION: Plasma 8-iso-prostaglandin F(2alpha) levels are elevated in patients with acute myocardial infarction. Endogenous oxidative stress may contribute to the pathogenesis of atherosclerosis and its complications, namely myocardial infarction.

Acute Disease↗
PubMed2006

Death during coronary angiography in a woman with cardiac amyloidosis.

Amyloidosis is a well-recognized systemic disease entity. Patients with cardiac amyloidosis have a poor prognosis; the median survival time after development of congestive heart failure is 4 months. We describe a 72-year-old woman with unsuspected cardiac amyloidosis who died during diagnostic coronary angiography. To our knowledge, this is the first report of this complication.

Aged↗
PubMed2006

Elective percutaneous coronary intervention without on-site cardiac surgery: clinical and economic implications.

BACKGROUND: Low procedural complication rates, barriers to access, and patient preference have encouraged the development of percutaneous coronary intervention (PCI) programs at centers that are often closer to home but without on-site cardiac surgical capability. OBJECTIVES: We compared clinical and economic outcomes associated with performing low-risk elective PCI at a community hospital without on-site cardiac surgery with those obtained at a more remote tertiary care center with on-site cardiac surgery. DESIGN AND MEASURES: We matched 257 patients undergoing low-risk, elective PCI at a community hospital (Immanuel St. Joseph's Hospital [ISJ] between January 27, 2000, and July 31, 2002) to 514 PCI patients treated at a tertiary care hospital (Saint Marys Hospital [SMH] between January 27, 2000, and April 30, 2002) based on clinical and lesion criteria. Clinical outcomes (in-hospital procedural success and target vessel failure during long-term follow up) and economic outcomes (direct medical costs, billed charges, and hospital length of stay [LOS]) were compared between groups. The Mayo Clinic PCI Registry (containing clinical, angiographic, and follow-up data) and administrative data were used in matching and outcomes assessment. RESULTS: Procedural success was achieved more often among ISJ-treated patients (99% vs. 95%; P = 0.02); however, no difference in target vessel failure rates was observed during a median follow-up time of 3.1 years (estimated 1-year event rate: 15.2% vs. 14.8%; P = 0.46). ISJ-treated patients incurred, on average, $3024 more in estimated total costs ($13,771 vs. $10,746; P < 0.001) and $6084 more in billed charges (P < 0.001), but incurred similar LOS post procedure (1.53 days). CONCLUSIONS: Similar clinical outcomes were achieved at a community hospital without on-site cardiac surgery but at significantly increased direct medical cost. Patients, providers, hospitals, payers, and policymakers should consider whether the benefits associated with locally provided specialized cardiovascular services warrant this additional cost.

Cardiac Care Facilities↗
PubMed2006

Outcomes of cardiopulmonary resuscitation and predictors of survival in patients undergoing coronary angiography including percutaneous coronary interventions.

We studied the outcome of cardiopulmonary resuscitation (CPR) in patients undergoing coronary angiography (CA) and/or percutaneous coronary interventions (PCI). Of 51,985 CA and PCI patients treated between January 1, 1990, and December 31, 2000, 114 required CPR. Records were reviewed for relationships between patient characteristics and various procedures and short-term survival. Long-term survival was compared with that of a matched cohort of patients who did not have an arrest during catheterization and a matched cohort from the general Minnesota population. Over the 11-year period, the overall incidence of CPR was 21.9 per 10,000 procedures. This rate decreased from 33.9 per 10,000 before 1995 to 13.1 per 10,000 after 1995. Overall survival to hospital discharge after CPR was 56.1%. Survival to discharge was less frequent with a history of congestive heart failure, previous coronary artery bypass graft surgery, hemodynamic instability during the procedure, and with prolonged or emergent catheterizations. Pulseless electrical activity (versus asystole or ventricular fibrillation) indicated very poor short-term survival. Interestingly, short-term survival was not related to the extent of coronary artery disease. Long-term survival of patients who survived cardiac arrest was comparable to that of those who did not have arrest during catheterization. In conclusion, the incidence of periprocedural CPR during diagnostic or interventional coronary procedures decreased after 1995. Patients who received CPR in the cardiac catheterization lab have a remarkably frequent survival to hospital discharge rate. Long-term survival of these patients is only minimally reduced.

Aged↗