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Biomedical subjects

Howard C Herrmann

Publications and source records attributed to Howard C Herrmann.

At least 37 records · Page 2Linked to original sources
PubMed2005

Percutaneous patent foramen ovale and atrial septal defect closure in adults: results and device comparison in 100 consecutive implants at a single center.

Closure of interatrial septal defects with percutaneous devices is increasingly common. However, the indications for closure and techniques for device implantation are diverse. We reviewed our first 100 consecutive implants to assess and compare the indications, results, complications, and evolution of techniques for percutaneous patent foramen ovale (PFO) and atrial septal defect (ASD) closure. The mean age of patients was 52 years and 70% were female. Paradoxical embolism was the predominant indication (94%) for PFO closure and significant left-to-right shunt was the most frequent indication (89%) for ASD closure. Implantation success was 94% with major complications in 3 patients (2.8%). Transesophageal echocardiography was utilized in the initial 27 procedures and then replaced by intracardiac echocardiography in subsequent ones, with an associated reduction in procedure and physician time. During 6 months of follow-up, 3 patients were readmitted for atrial arrhythmias (2 patients) and an MRI-negative neurologic event (1 patient). Echocardiography at 6 months in 83% of the PFO patients revealed moderate and severe positive contrast studies for right-to-left shunting in one third of patients, with differences between devices and insertion techniques. This single-center experience with percutaneous device closure of PFO and ASD in adults demonstrates excellent results with few complications.

Catheterization↗
PubMed2005

FilterWire distal embolic protection device for vein graft stenting: initial single-center experience.

BACKGROUND: Saphenous vein graft (SVG) intervention is associated with a significant incidence of major adverse cardiac events (MACE) related to distal vessel embolization. The FilterWire distal embolic protection device has recently been approved as an adjunct to SVG intervention. We report here our initial experience in a single center in 30 consecutive patients using this device in SVG stenting. HYPOTHESIS: This study examined the outcomes and complications associated with these devices, as well as whether proficiency with the devices increased with greater experience and whether there were measurable outcome differences between devices. METHODS: We retrospectively identified all patients in whom a FilterWire device was placed at our hospital between June 2001 and June 2004. RESULTS: The device was successfully deployed in 29 of 30 patients, and all patients were stented successfully. Overall MACE rate was 6.6%, consistent with reports in larger multicenter clinical trials. Transient decreases in flow were noted while the device was in place in six patients, but improved in five patients with device removal. CONCLUSIONS: This early experience in a single center using FilterWire embolic protection indicates that excellent clinical results can be obtained by the adoption of filter protection for SVG intervention, without evidence for a detrimental learning curve.

Aged↗
PubMed2005

Percutaneous valve therapies.

Recent innovations have occurred in the treatment of valvular heart disease so that we now stand at the very beginning of a field that is likely to show considerable growth in the future. These innovations include the introduction of self-expanding and balloon-expandable stents containing bioprosthetic heart valves, and other valvular implants and techniques for the repair and treatment of valvular heart disease. Previously, the field of nonsurgical cardiac valve repair and replacement consisted solely of the use of balloon valvuloplasty for valvular stenosis. The ability to address aortic stenosis more definitively than with balloon valvuloplasty and to address regurgitant valve lesions will greatly expand the patients who can be treated without surgery. Percutaneous valve repair and replacement is at an early stage with a variety of techniques that are undergoing investigation. Similar to the initial development of balloon angioplasty for coronary artery disease, improvements in technology, techniques, and experience will be necessary before we can reproduce the excellent results achieved today with surgery.

Journal Article↗
PubMed2005

The relation of renal function to ischemic and bleeding outcomes with 2 different glycoprotein IIb/IIIa inhibitors: the do Tirofiban and ReoPro Give Similar Efficacy Outcome (TARGET) trial.

BACKGROUND: Renal function significantly impacts morbidity and mortality after a percutaneous coronary intervention. Platelet glycoprotein (GP) IIb/IIIa inhibitors reduce ischemic complications during percutaneous coronary intervention; little is known of whether their safety and efficacy are influenced by renal function. In particular, whether outcome differences exist between agents that are renally excreted (tirofiban) or not (abciximab) in patients with mild renal impairment is not known. METHODS: The TARGET trial randomized 4623 patients to tirofiban or abciximab. In this analysis, patients were grouped in creatinine clearance quartiles (<70, 70-90, 90-114, >114 mL/min) and analyzed for efficacy and bleeding risk. Univariate and multivariate analyses were performed to identify interactions between GP IIb/IIIa inhibitor used and creatinine clearance with respect to ischemic outcomes and bleeding. RESULTS: Using unadjusted logistic regression tests for trend, 30-day death/myocardial infarction/urgent target vessel revascularization was greater in patients with lower creatinine clearances (7.3%, 8.5%, 5.1%, and 5.8%, P = .005), as were both major and minor bleeding. There was no interaction between assigned GP IIb/IIIa inhibitor, creatinine clearance and ischemic outcome, major bleeding or minor bleeding. CONCLUSIONS: Both ischemic and bleeding complications are highest in the lowest creatinine clearance quartile of patients treated with GP IIb/IIIa inhibitors. Although tirofiban is renally cleared and abciximab is not, there was no interaction between these GP IIb/IIIa inhibitors and creatinine clearance regarding ischemic or bleeding events.

Abciximab↗
PubMed2005

Transcatheter device closure of interatrial septal defects in patients with hypoxia.

BACKGROUND: There has been growing interest in transcatheter closure of interatrial septal defects (IASDs) for a variety of indications, but reports are limited in patients with hypoxia from right-to-left shunting. METHODS: Between August 2000 and October 2004, 181 patients were referred to our institution for elective closure of a patent foramen ovale (PFO) or atrial septal defect (ASD). Among these patients, 10 (5.5%) underwent closure for hypoxia due to persistent or intermittent right-to-left shunting. Clinical evaluation, including echocardiography with color Doppler and agitated saline, was performed in all patients to determine the degree of right-to-left shunting. Defects were closed with Amplatzer (n = 4) or Cardioseal (n = 6) devices, under transesophageal (TEE) or intracardiac echocardiography (ICE) guidance. RESULTS: Mean age was 62.7 years (range: 31-88 years) with 70% female. Characteristics for closure included four patients with persistent hypoxia and six with intermittent hypoxia, including two with platypnea-orthodeoxia syndrome. All patients had echocardiography showing moderate (n = 6) or severe (n = 4) shunting. Patients had significant comorbidities, including chronic lung disease requiring supplemental oxygen (n = 5) and congestive heart failure (n = 2). TEE guidance was used in three patients, and ICE was performed in the remainder. Mean closure device diameter was 27 mm. Mean preprocedural arterial oxygen saturation of 86.7% improved to 95.9% immediately after closure, with color Doppler and agitated saline revealing the absence of (n = 5) or mild (n = 5) shunting. In-hospital major complications were limited to one patient with a transient ischemic attack after an initially unsuccessful closure attempt. CONCLUSIONS: Percutaneous closure of IASDs in a heterogeneous group of patients with hypoxia can be safely and effectively performed. The procedure results in immediate arterial saturation improvement and reduced right-to-left shunting.

Adult↗
PubMed2005

Acute decompensation of hypertrophic obstructive cardiomyopathy secondary to A-V disassociation: successful treatment with a combination of alcohol septal ablation and permanent pacemaker.

Alcohol septal ablation is increasingly being offered as a therapy for patients with hypertrophic obstructive cardiomyopathy. The procedure is most often performed in stable patients with a history of increasing symptoms. We describe a patient with hypertrophic obstructive cardiomyopathy with an acute decompensation secondary to the development of complete heart block. The patient's hemodynamics demonstrates the importance of atrial-ventricular (A-V) synchrony in this disease process. This case report is also a unique description of alcohol septal ablation being performed emergently to improve hemodynamics and the urgent implantation of a permanent pacemaker to return A-V synchrony.

Acute Disease↗
PubMed2005

Use of a new 8 French intracardiac echocardiographic catheter to guide device closure of atrial septal defects and patent foramen ovale in small children and adults: initial clinical experience.

Intracardiac echocardiography (ICE) has become an accepted imaging modality to guide device closure of atrial septal defect (ASD) and patent foramen ovale (PFO). The use of ICE to guide device closure of ASDs in small children (< 20 kg) has been very limited. We report on the use of a new, 8 Fr ICE catheter that possesses full color Doppler capabilities to guide device closure of ASDs in small children as well as to guide device closure of ASDs and PFOs in adult patients.

Adult↗
PubMed2004

Impact of age, race, and sex on the ability of B-type natriuretic peptide to aid in the emergency diagnosis of heart failure: results from the Breathing Not Properly (BNP) multinational study.

BACKGROUND: B-type natriuretic peptide (BNP) is secreted from the cardiac ventricles in response to increased wall tension. METHODS: The Breathing Not Properly Multinational Study was a 7-center, prospective study of 1586 patients who presented to the Emergency Department with acute dyspnea and had BNP measured with a point-of-care assay upon arrival. The gold standard for congestive heart failure (CHF) was adjudicated by two independent cardiologists, blinded to BNP results, who reviewed all clinical data and standardized scores. The current study explores the effect of these variables on BNP decision statistics as well as the impact that changing cutoffs might have on the cost-effectiveness of diagnostic decisions that use BNP information. RESULTS: Significant differences in CHF rates were found on the basis of age (P <.001) and racial group (P =.020) but not sex (P =.424). BNP levels increased with increasing age (P <.001). To evaluate potential differences in the diagnostic utility of BNP levels as a function of demographic variables, separate receiver operating characteristic curves were performed. BNP was a stronger predictor in younger subjects than in older subjects and slightly weaker for female patients than for male patients (area under the curve = 0.918 and 0.870, respectively). An even smaller difference was noted between the white and black racial groups (area under the curve = 0.888 and 0.903, respectively). The differences in specificity as a function of age are larger than other differences in specificity or sensitivity. When logistic regression was used in a multivariate approach to combine the demographic variables with BNP information in the prediction of CHF, only BNP contributed significantly to the prediction of acute CHF. When the model was expanded to include terms for the interaction of each of the demographic variables with log(10) BNP, a significant interaction was found for sex. Since the relative consequences of false-positives and false-negatives are unlikely to be equivalent, the BNP cut-points that would be selected based on the current data as a function of relative costs are presented. Sharply rising consequences are seen for BNP cut-points >100 pg/mL. CONCLUSIONS: If one assumes that failing to treat cases of CHF is worse than treating negative cases, then relatively low BNP cut-points (eg, not >100 pg/mL) should be used in patients presenting to the Emergency Department with a chief complaint of dyspnea, regardless of age, sex, or ethnicity.

Age Distribution↗
PubMed2004

The effect of diabetes on B-type natriuretic peptide concentrations in patients with acute dyspnea: an analysis from the Breathing Not Properly Multinational Study.

OBJECTIVE: Diabetes has been implicated in reduced myocardial compliance and changes in the intercellular matrix of the myocardium. We determined the effect of diabetes on B-type natriuretic peptide (BNP) concentrations in patients presenting to the emergency department with dyspnea. RESEARCH DESIGN AND METHODS: The Breathing Not Properly Multinational Study was a prospective evaluation of 1,586 patients. A subset of 922 patients was obtained and subdivided into the following groups: group 1 (n = 324), neither diabetes nor heart failure; group 2 (n = 107), diabetes and no heart failure; group 3 (n = 247), no diabetes and heart failure; group 4 (n = 183), both diabetes and heart failure; group 5 (n = 41), heart failure history with no diabetes; and group 6 (n = 20), heart failure history with diabetes. Patients from groups 1, 3, and 5 were matched to groups 2, 4, and 6, respectively, to have the same mean age, sex distribution, BMI, renal function, and New York Heart Association (NYHA) classification (for heart failure). RESULTS: There was no significant difference in median BNP levels between diabetes and no diabetes among no heart failure patients (32.4 vs.32.9 pg/ml), heart failure patients (587 vs. 494 pg/ml), and those with a heart failure history (180 vs. 120 pg/ml). Receiver-operating characteristic curve analysis of the area under the curve for BNP was not different in diabetic versus nondiabetic patients (0.888 vs. 0.878, respectively). However, in a multivariate model, diabetes was an independent predictor of a final diagnosis of heart failure (odds ratio 1.51, 95% CI 1.03-2.02; P < 0.05). CONCLUSIONS: History of diabetes does not impact BNP levels measured in patients with acute dyspnea in the emergency department. Despite the impact of diabetes on the cardiovascular system, diabetes does not appear to confound BNP levels in the emergency department diagnosis of heart failure.

Acute Disease↗
PubMed2003

Angiographic variables predict increased risk for adverse ischemic events after coronary stenting with glycoprotein IIb/IIIa inhibition: results from the TARGET trial.

OBJECTIVES: We sought to assess whether pre-procedural angiographic characteristics are associated with adverse clinical outcomes after coronary stenting with glycoprotein IIb/IIIa inhibition. BACKGROUND: Ischemic complications after balloon angioplasty are associated with pre- and post-procedural angiographic variables. However, in the current era of stenting with IIb/IIIa inhibition, it is unknown whether angiographic features assessed before intervention confer an increased risk of adverse procedural and subsequent clinical outcomes. METHODS: In the Do Tirofiban and ReoPro Give Similar Efficacy Outcomes? Trial (TARGET), 4,809 patients undergoing planned stenting were randomized to tirofiban or abciximab. Baseline demographic, clinical, and angiographic variables were obtained. Clinical end points were recorded at 30 days and six months. The relationship between angiographic variables and adverse clinical outcomes was assessed. RESULTS: Patients with the combination of thrombus, lesion eccentricity, and lesion length >20 mm had a 21.4% composite incidence of death, myocardial infarction, or urgent target vessel revascularization (TVR) at 30 days, compared with 4.2% in those patients without these high-risk features (hazard ratio [HR] 3.24, p < 0.001). After adjustment, the risk was independently associated with thrombus (HR 1.40, p = 0.034), eccentricity (HR 1.67, p < 0.001), and lesion length >20 mm (HR 1.89, p < 0.001). The risk of six-month TVR was independently associated with left anterior descending coronary artery lesions (HR 1.46, p < 0.001), restenotic lesions at baseline (HR 1.58, p = 0.006), and lesion length (HR 1.19, p = 0.03). CONCLUSIONS: Patients with thrombus, eccentric lesions, or lesion length >20 mm are at high risk for ischemic outcomes after coronary stenting, despite IIb/IIIa inhibition. Further research into novel anti-thrombotic therapies or procedural strategies is necessary for these patients.

Abciximab↗