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Table 2 (continued) Baseline Total testosterone (ng/dL) Placebo 384.7 ± 405.8 Bosentan 372.7 ± 422.2 Cortisol (μg/dL) Placebo 13.0 ± 4.5 Bosentan 17.2 ± 6.3 Dehydroepiandrosterone sulfate (μg/dL) Placebo 289.7 ± 161.7 Bosentan 342.5 ± 201.9

Week 1

Week 2

Week 4

Week 6

Week 8

344.4 ± 339.1 371.9 ± 438.5

378.1 ± 353.5 418.1 ± 448.1

411.9 ± 406.6 418.8 ± 438.9

386.8 ± 351.9 423.4 ± 445.5

399.1 ± 373.5 420.4 ± 426.0

14.6 ± 3.6 18.8 ± 8.0

13.2 ± 3.9 18.2 ± 7.5

14.7 ± 4.5 17.7 ± 6.6

327.9 ± 203.4 358.7 ± 190.3

311.0 ± 181.9 350.0 ± 174.1

317.1 ± 174.5 362.1 ± 196.3

14.3 ± 4.9 16.8 ± 6.4

292.5 ± 163.1 345.2 ± 194.8

14.4. ± 4.6 17.5 ± 6.8

295.2 ± 163.5 355.3 ± 187.7

Note * indicates significant difference (P b 0.05) between groups.

[7] Berthon P, Fellmann N. General review of maximal aerobic velocity measurement at laboratory. Proposition of a new simplified protocol for maximal aerobic velocity assessment. J Sports Med Phys Fitness 2002;42:257–66. [8] Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009;30:2493–537.

[9] Humbert M, Segal ES, Kiely DG, Carlsen J, Schwierin B, Hoeper MM. Results of European post-marketing surveillance of bosentan in pulmonary hypertension. Eur Respir J 2007;30:338–44. [10] van Giersbergen PL, Gnerre C, Treiber A, Dingemanse J, Meyer UA. Bosentan, a dual endothelin receptor antagonist, activates the pregnane X nuclear receptor. Eur J Pharmacol 2002;450:115–21.

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A simple approach for the reduction of knotted coronary catheters during transradial coronary angiography☆ Dingguo Zhang 1, Enzhi Jia 1, Jun Chen 1, Lei Xu, Zhijian Yang, Chunjian Li ⁎ Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China

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Article history: Received 25 August 2013 Accepted 23 November 2013 Available online 4 December 2013 Keywords: Percutaneous coronary intervention Complication Goose neck snare

Transradial access is currently the most popular vascular access for cardiac catheterization since Lucien Campeau described it initially in 1989 [1,2]. It is widely accepted to be a very safe and viable approach, with significantly less incidence of major access-related complications compared to the transfemoral approach. Most interventional cardiologists prefer performing the procedure at the right side of the patient

☆ Funding: This work was supported by a grant from the National Natural Science Funding of China (81170181), and a Project Funded by the Priority Academic Program Development of Jiangsu Higher Education Institutes (PAPD). ⁎ Corresponding author at: Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, 300, Guangzhou Road, Nanjing, China. Tel.: + 86 25 6813 6018; fax: + 86 25 83674380. E-mail address: [email protected] (C. Li). 1 Contributed equally to this work.

since the right radial access is more convenient for manipulating catheters and devices [2–4]. In some cases, catheters can become entrapped looped/kinked during transradial catheterization in the brachial artery. Regular maneuvers and manipulations to disengage the catheter might be unsuccessful due to the narrow diameter of the artery. We present two cases of coronary angiography complicated by right coronary catheter knotting and present a simple approach for their reduction in the brachial artery using the Amplatz GooseNeck Snare. Informed consents were obtained from both patients. The first case was a 50-year-old woman with serious aortic valve stenosis who was transferred to the catheter lab for coronary angiography prior to the valve replacement. After considerable torquing of the Judkins right coronary catheter (JR3.5) (Cordis Europa, Roden, Holland), the right coronary artery was engaged and standard views were acquired. Upon withdrawal of the JR3.5 catheter, resistance was encountered and a knot was noted in the brachial artery. The second case was a 71-year-old woman who was admitted for percutaneous coronary intervention due to exertional chest pain. Her subclavian and aorta vessels were noted to be very tortuous while the doctors were performing coronary artery angiography. On attempting intubation of the right coronary artery a knot was tied in the right brachial artery. In the above cases the same technique was used when standard attempts failed to resolve the knot. On fluoroscopy, the catheter was found entrapped and kinked on itself in the brachial segment (Figs. 1A and 2A). The guidewire couldn't be able to pass through the knot, and applying clockwise or anticlockwise rotation or gentle

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Fig. 1. A. Kinked and looped 6-Fr JR3.5 catheter in the right brachial artery. B. Snare in open position at the tip of the kinked JR3.5 catheter. C. Final successful unlooping of the JR3.5 catheter with wire advancement before removal.

Fig. 2. A. Kinked and looped 6-Fr JR3.5 catheter in the right brachial artery. B. Snare in open position at the tip of the kinked JR3.5 catheter. C. Final successful unlooping of the JR3.5 catheter with wire advancement before removal. D. Coronary angiography showing significant lesions in LAD and LCX. E. Coronary angiography showing significant lesions in RCA. F. Coronary angiography after stenting showing TIMI 3 flow in LAD and LCX. G. Coronary angiography after stenting showing TIMI 3 flow in RCA.

traction couldn't reduce the knot. Attempts to unravel the catheter with gentle rotation caused severe forearm pain. Thus, the catheter could not withdraw from the brachial artery using the regular maneuvers. The patients would undergo surgery if no effective method could solve the problem. However, we successfully retrieved the catheters by using the goose neck snare and the process was as follows. After right femoral artery puncture, a 6 French JR3.5 guiding catheter was used. Through the guiding catheter an Amplatz GooseNeck Snare (Microvena, St. Paul, MN) was passed and grasped the kinked catheter tip in the aorta arch. The entrapped catheter was then pulled simultaneously from the two ends under the help of the snare, and the looped catheter was straightened (Figs. 1B and 2B). After releasing the snare (Figs. 1C and 2C), the kinked catheter was unraveled with a 0.35 inch guidewire and was successfully removed from the radial artery. In Case 1, no stenosis was found in the coronary artery after angiography examination. Aortic valve replacement and ascending aortic valvuloplasty were performed successfully one week later. In Case 2, after removal of the catheter, angiography was completed by the right femoral approach and results showed occlusion of the left anterior descending artery (LAD) and severe stenosis in both the left circumflex artery (LCX) and right coronary artery (RCA) (Fig. 2D and 2E). Percutaneous coronary interventions of the LAD and LCX were successfully performed using 4 drug eluting stents (Fig. 2F). Four days

later, RCA intervention was successfully performed by the radial approach (Fig. 2G). The patient was discharged 2 days later. Minor looping of the coronary catheter is common during left heart catheterization and is usually the result of excessive torquing of the catheter, especially in a tortuous subclavian artery. It usually can be managed with gentle rotation in the opposite direction, and thus goes unnoticed without complications. Sometimes a guidewire can be advanced to the knot and with gentle traction of the catheter the wire may pass through and open the knot. However, more complex knots may rotate in the direction of torque adding further problems. This looped/kinked catheter can get entrapped and may require surgery for retrieval. Furthermore, perforating the catheter is of risk if excessive force is used. A single case report has suggested that a second catheter through the contralateral femoral artery can facilitate manipulation of a kinked catheter [5]. The second catheter is passed alongside the knotted catheter and directed through the loop of the knot. The knot is then pulled back to the bifurcation of the aorta and moved gently to and fro enabling knot reduction. A further technique with W grabber device has also been described [6]. However, the above-mentioned techniques have their limitations in the form of dependence on significant knot laxity and would therefore not be successful in the case of tighter knots. There is a great advantage of the technique that we have described. In the two cases we used the Amplatz GooseNeck Snare, which has the advantage of being open and can fixate the catheter from the side easily. Closed snares would require passing the

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device over the free end of the catheter. To the best of our knowledge, there is only one similar case described previously [7], where the authors used an Amplatz GooseNeck Snare to remove an entrapped catheter in the radial artery. In the case of tight catheter knots that do not respond to standard maneuvers, we would recommend the use of this safe and easily applied technique, saving the patient from unplanned surgical intervention. References [1] Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7.

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[2] Ratib K, Mamas MA, Routledge H, Fraser D, Nolan J. Access site selection for primary PCI: the evidence for transradial access is strong. Heart 2012;98:1392 [author reply3]. [3] Carrillo X, Mauri J, Fernandez-Nofrerias E, Rodriguez-Leor O, Bayes-Genis A. Safety and efficacy of transradial access in coronary angiography: 8-year experience. J Invasive Cardiol 2012;24:346–51. [4] Schueler A, Black SR, Shay N. Management of transradial access for coronary angiography. J Cardiovasc Nurs 2013;28:468–72. [5] Cohen HR, Deutsch AM, Ryvicker MJ, Schatz SL. Reduction of catheter knots. Radiology 1980;134:243–5. [6] Tanner MA, Ward D. Percutaneous technique for the reduction of knotted coronary catheters. Heart 2003;89:1132–3. [7] Kim JY, Moon KW, Yoo KD. Entrapment of a kinked catheter in the radial artery during transradial coronary angiography. J Invasive Cardiol 2012;24:E3–4.

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Mediterranean diet and heart rate: The PREDIMED randomised trial☆ M. García-López a,b, E. Toledo b,c, J.J. Beunza b,c, F. Aros c,d, R. Estruch c,e, J. Salas-Salvadó c,f, D. Corella c,g, E. Ros c,h, M.I. Covas c,i, E. Gómez-Gracia j, M. Fiol c,k, R.M. Lamuela-Raventós c,l, J. Lapetra c,m, P. Buil-Cosiales b,c,n, S. Carlos b, L. Serra-Majem c,o, X. Pintó c,p, V. Ruiz-Gutiérrez c,q, M.A. Martínez-González b,c,⁎ a

Department of Cardiology, Clinic University of Navarra, Pamplona, Spain Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain c CIBER Fisiopatologia de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain d Department of Cardiology, University Hospital of Alava, Vitoria, Spain e Department of Internal Medicine, Institut d'Investigacions Biomèdiques Augusti Pi Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain f Human Nutrition Unit, Biochemistry and Biotechnology Department, Hospital Universitari de Sant Joan de Reus, IISPV, Universitat Rovira i Virgili, Reus, Spain g Department of Preventive Medicine and Public Health, University of Valencia, Valencia, Spain h Lipid Clinic, Endocrinology and Nutrition Service, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain i Cardiovascular Epidemiology Unit, Municipal Institut for Medical Research (IMIM), Barcelona, Spain j Department of Preventive Medicine, School of Medicine, University of Malaga, Málaga, Spain k University Institute for Health Sciences Investigation, Hospital Son Espases, Palma de Mallorca, Spain l Nutrition and Food Science Department, CaRTA, INSA Pharmacy School, University of Barcelona, Spain m Department of Family Medicine, Primary Care Division of Sevilla, San Pablo Health Center, Sevilla, Spain n Servicio Navarro de Salud, Osasunbidea, Pamplona, Spain o Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Spain p Lipids and Vascular Risk Unit, Internal Medicine, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain q Instituto de la Grasa, Consejo Superior de Investigaciones Cientificas, Sevilla, Spain b

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Article history: Received 27 August 2013 Accepted 23 November 2013 Available online 4 December 2013 Keywords: Mediterranean diet Clinical trial Heart rate

A higher heart rate (HR) has been associated with increased total and cardiovascular mortality [1,2]. Clinical trials support the beneficial effect of decreasing HR in patients with heart failure [3] and ischaemic heart disease [4]. A recent cross-sectional study showed that closer adherence to the Mediterranean diet (MeDiet) was related to lower HR [5]. We evaluated the association between adherence to the ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ⁎ Corresponding author at: Department of Preventive Medicine and Public Health, University of Navarra, CP. 31008, Pamplona, Spain. Tel.: +34 948 425 600; fax: + 34 948 425 740. E-mail address: [email protected] (M.A. Martínez-González).

MeDiet (measured with a score from 0 to 14 obtained by a validated screener [6]) and HR using both a cross-sectional and a longitudinal analysis of the PREDIMED trial [7,8]. We assessed 7447 men and women (55–80 years) initially free of cardiovascular disease who had either type 2 diabetes or three or more cardiovascular risk factors, as previously described [7,8]. Participants were randomly assigned to one of three diets: MeDiet supplemented with extra virgin olive oil (MeDiet + EVOO), MeDiet supplemented with mixed nuts (MeDiet + nuts), or control diet. Blood pressure and HR were measured by trained nurses in triplicate using a validated semiautomatic oscillometer (Omron HEM-705CP, Hoofddorp, the Netherlands) with a 5-min interval between each measurement. The study complies with the Declaration of Helsinki, the study protocol was approved by the Institutional Review Board of all participating centres and all participants provided written informed consent. Out of the 7447 trial participants, 7128 had available data for analyses. We used analysis of covariance and ordinary least squares regression for the cross-sectional analyses. For the longitudinal analyses, we used generalized estimating equations (GEE) with STATA 12.1 assuming an unstructured correlation matrix. The dependent variable was HR during follow-up (yearly repeated measurements). We assessed 3 exposures: baseline adherence to

A simple approach for the reduction of knotted coronary catheters during transradial coronary angiography.

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