Ischemic postconditioning, as described, can be expeditiously performed during PCI for STEMI. Concordant changes in coronary flow reserve and ST segment resolution, measures of microcirculatory function, and myocardial perfusion, were greater in postconditioned patients.

The relative impact of transesophageal echocardiography (TEE) on the management of patients with specific embolic events, namely nonhemorrhagic cerebrovascular accident (CVA), transient ischemic attack (TIA), or peripheral embolism is controversial. The impact of TEE in 234 adult subjects with CVA (n = 141), TIA (n = 59), or peripheral embolism (n = 34) was determined. TEE was diagnostic of a potential embolic source in 61%, 51%, and 62% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). TEE results changed medication or surgical treatment in 32%, 22%, and 32% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). Anticoagulation was started on the basis of TEE findings in 11%, 12%, and 18% of patients with CVA, TIA, and peripheral embolism, respectively (P = NS). In 77% of all patients, TEE findings confirmed as appropriate the empiric decision made prior to TEE, to anticoagulate (60%; 12/20) or not to anticoagulate (79%; 168/214). These data demonstrate that TEE findings have a significant and similar impact on the clinical management of patients with various types of potential embolism. Future studies addressing the effectiveness of treatment, guided by TEE findings, in the prevention of recurrent embolic events are needed.

SummaryBackground: Pulmonary capillary wedge pressure (PCWP) is a useful index of preload and an important determinant of cardiac function.Hypothesis: We postulated that the rate of blood propagating into the left atrium (LAIF-PR) would be a useful measure of PCWP in critically ill patients.Methods: Fifty-two critically ill patients (36 men/16 women) receiving mechanical ventilation were studied by multiplane transesophageal echocardiography (TEE). Left atrial inflow propagation rate was measured in systole and diastole as the slope of the color M-mode signal entering the left atrium from the right upper pulmonic vein.Results: Systolic and diastolic LAIF-PRs were feasible in 49 and 44 patients, respectively. Mean (± 1 standard deviation) LAIF-PR in systole was 40 ± 26 cm/s (range 11-132) and in diastole 34 ± 22 cm/s (range 5-102). Negative correlations with PCWP (mean 19 ± 9 mmHg; range 3-40) were good for LAIF-PR in systole (r = Ϫ0.71, standard error of estimate [SEE] = 6 mmHg; p < 0.0001) and diastole (r = Ϫ0.71, SEE = 6 mmHg; p < 0.0001). Mean ejection fraction was 52 ± 22% (range 15-88) and cardiac output was 6.97 ± 3.52 l/min (range 2.26-17.93). Multivariate regression showed PCWP as the only independent predictor of systolic (p < 0.0001) and diastolic (p < 0.0001) LAIF-PR among age, heart rate, cardiac output, ejection fraction, or left atrial diameter.Conclusions: Left atrial inflow propagation rate derived by color M-mode TEE aligned with the right upper pulmonic vein is a promising new index of preload. Future studies addressing the determinants of LAIF-PR, such as left atrial compliance, are needed.

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Thoracotomy patch leads used for implantable cardioverter defibrillators (ICDs) are generally safe and effective. We describe two patients in whom a late complication of patch lead migration occurred years after the original implants, causing a bronchopleural fistula in one and lingular lobe collapse in the other patient. We conclude that patch migration is a late but possible complication of extrapericardial ICD leads, and should be suspected in patients who present with hemoptysis, atypical pneumonia, or lung collapse after the initial ICD surgery.