Introduction

Post-contrast acute kidney injury (PC-AKI) develops in a significant proportion of patients with CKD after invasive cardiology procedures and is strongly associated with adverse outcomes.

Objective

We sought to determine whether increased intrarenal nitric oxide (NO) would prevent PC-AKI.

Methods

To create a large animal model of CKD, we infused 250 micron particles into the renal arteries in 56 ± 8 kg pigs. We used a low-frequency therapeutic ultrasound device (LOTUS - 29 kHz, 0.4 W/cm²) to induce NO release. NO and laser Doppler probes were used to assess changes in NO content and blood flow. Glomerular filtration rate (GFR) was measured by technetium-diethylene-triamine-pentaacetic acid (Tc-99m-DTPA) radionuclide imaging. PC-AKI was induced by intravenous infusion of 7 cm³/kg diatrizoate. In patients with CKD, we measured GFR at baseline and during LOTUS using Tc-99m-DTPA radionuclide imaging.

Results

In the pig model, CKD developed over 4 weeks (serum creatinine [Cr], mg/dL, 1.0 ± 0.2-2.6 ± 0.9, p < 0.01, n = 12). NO and renal blood flow (RBF) increased in cortex and medulla during LOTUS. GFR increased 75 ± 24% (p = 0.016, n = 3). PC-AKI developed following diatrizoate i.v. infusion (Cr 2.6 ± 0.7 baseline to 3.4 ± 0.6 at 24 h, p < 0.01, n = 3). LOTUS (starting 15 min prior to contrast and lasting for 90 min) prevented PC-AKI in the same animals 1 week later (Cr 2.5 ± 0.4 baseline to 2.6 ± 0.7 at 24 h, p = ns, n = 3). In patients with CKD (n = 10), there was an overall 25% increase in GFR in response to LOTUS (p < 0.01).

Conclusions

LOTUS increased intrarenal NO, RBF, and GFR and prevented PC-AKI in a large animal model of CKD, and significantly increased GFR in patients with CKD. This novel approach may provide a noninvasive nonpharmacological means to prevent PC-AKI in high-risk patients.

The outcome of posteroseptal accessory pathway ablation by direct current (DC) shocks delivered just outside the os of the coronary sinus was studied in 21 patients. Electrocardiographic and electrophysiological parameters as well as phase image patterns of equilibrium multiple-gated blood-pool scintigrams were studied to determine their usefulness in predicting the success of ablation. A second free-wall pathway was documented by electrophysiological or surgical findings in six patients, and the value of phase images in detecting this second pathway was studied as well. Ablation was successful in 57%. The cumulative mean energy of DC shocks amounted to 524 +/- 170 joules and was not predictive of ablation outcome, neither was the mean ventriculoatrial (VA) conduction time. The predictive value of the 12-lead maximally preexcited electrocardiogram was poor in the 15 patients with a single posteroseptal bypass tract. A new method to triangulate the site of the earliest phase angle on the atrioventricular (AV) valve plane successfully localized the bypass pathway in 14 of those patients. No specific phase pattern predicted successful ablation except for a symmetrical, concentric peripheral phase progression found to be predictive of ablation success in the four patients who showed this pattern. Phase analysis was able to localize the second, nonposteroseptal pathway in four of six patients. This study showed that a concentric peripheral phase progression in the gated blood-pool scintigrams is predictive for ablation success in patients with posteroseptal pathways. A free-wall localization of the earliest phase angle is suggestive of a second bypass tract in this area.