Abstract: Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.
Abstract: Pyoderma gangrenosum is an uncommon, idiopathic, chronic ulcerative inflammatory skin disease characterized by a rapidly progressive necrosis of the wound edges, and mimics a postoperative infection. Few cases have been reported after cardiothoracic surgery. We present a case of a pyoderma gangrenosum occurring after coronary artery bypass graft.
Abstract: BACKGROUND: The continuity equation (CE) represents the 'gold standard' for the evaluation of aortic valve area in patients with aortic stenosis, but it is time-consuming and subject to error, and can be technically demanding. Recently, a new echocardiographic nonflow corrected index was introduced and demonstrated excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bioprostheses. This new index, the ejection fraction (EF)-velocity ratio (EFVR), is obtained by dividing the percentage left ventricular EF by the maximum aortic gradient. OBJECTIVE: To assess the usefulness of this echocardiographic index for quantifying the EOA in patients with aortic bioprosthesis and left ventricular dysfunction. METHODS: A total of 70 patients (25 women and 45 men) with aortic bioprosthesis and left ventricular dysfunction (EF of 49% or less) were studied. The mean (+/- SD) age of the study population was 71.4+/-9 years. The EOA was evaluated, both by the CE and by the EFVR. RESULTS: A significant linear correlation between the CE and the EFVR was found (r=0.80; P<0.0001). The receiver operating characteristic curve analysis showed good agreement between the CE and the EFVR. An EFVR value of 1.15 or less was found to have a good sensitivity (89%) and good specificity (91%) in identifying patients with an EOA of 1.0 cm2 or smaller, with positive and negative predictive values of 79% and 95%, respectively. CONCLUSIONS: The EFVR, a simple index that is less time-consuming than the CE, allows the identification of patients with aortic bioprosthesis stenosis with excellent sensitivity and specificity. It may be taken into consideration in clinical practice for the evaluation of patients with aortic bioprosthesis stenosis and left ventricular dysfunction.
Abstract: BACKGROUND: Patients with previous myocardial revascularization, even if symptom-free, remain at risk of subsequent cardiac events, so that a non-invasive tool able to stratify this population is wishful. OBJECTIVES: To assess the prognostic value of dipyridamole stress echocardiography (DipSE) in a population of asymptomatic patients following complete myocardial revascularization, either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS: We retrospectively evaluated 104 consecutive symptom-free patients (mean age 67+/-9.3 years, 75 males) with recent (<12 months) complete myocardial revascularization (48% PCI, 52% CABG) undergoing DipSE. Ischemia was defined as the onset of a new or worsening wall motion abnormality during DipSE. The composite end point of the study was cardiac death and non-fatal acute coronary syndrome. RESULTS: Myocardial ischemia was identified in 23 patients (22.1%). During a mean follow up of 21 months, 7 (30.4%) out of these patients suffered cardiac events. Among the remaining 81 patients (77.9%) with negative DipSE results, 7 (8.6%) experienced cardiac events. At multivariable analysis only a positive DipSE (odds ratio 3.9, P=0.03), wall motion score index at peak of stress (OR 3.6, P=0.04) and a prior myocardial infarction (odds ratio 3.5, P=0.04) achieved statistical significance for cardiac events. Moreover, DipSE effectively stratified patients into a high and low risk group according to presence of inducible ischemia (event rate per year 16% vs 4.8%, P=0.02). CONCLUSIONS: DipSE yields appropriate risk stratification and provides incremental prognostic value over clinical variables even in asymptomatic patients with prior complete myocardial revascularization. A negative DipSE portends a benign prognosis (<5% event rate/year) in such population.
Abstract: BACKGROUND: Altitude-induced sympathetic hyperactivity can elicit rhythm disturbances in healthy subjects, in particular during exercise. AIM: To asses the real susceptibility of healthy myocardium to malignant ventricular arrhythmias during exercise at high altitude using microvolt T-wave alternans (MTWA). METHODS: We evaluated eight healthy trained participants (one female, 42 +/- 9 years) during a mountain climbing expedition on Gashembrum II (Pakistan, 8,150 m). MTWA and heart rate variability (HRV) were measured in each subject at sea level and at high altitude, both under rest conditions and during exercise. MTWA was determined with the modified moving average method. HRV was expressed as root mean square of successive differences. RESULTS: Rest HRV at high altitude was significantly lower compared to rest HRV at sea level (36 +/- 5 vs 56 +/- 9 ms, P = 0.003). HRV during exercise was significantly lower with respect to rest condition both in normoxia (46 +/- 7 vs 56 +/- 9 ms, P = 0.0001) and hypoxia (27 +/- 4 vs 36 +/- 5 ms, P = 0.005). Moreover, HRV was significantly lower during exercise at high altitude compared to exercise at sea level (27 +/- 4 vs 46 +/- 7 ms, P = 0.0002) and arrhythmias were more frequent during exercise in hypoxia. Nevertheless, MTWA was absent under rest conditions both at sea level and at high altitude and minimally evoked during exercise in both conditions (22 +/- 3 microV and 23 +/- 3 microV, respectively, P = 0.2). CONCLUSIONS: In spite of an enhanced sympathetic activity, MTWA testing during exercise at high altitude was negative in all participants. Healthy trained subjects during exercise under hypoxia seem to be at low risk for dangerous arrhythmias.
Abstract: We describe a rare case of superior vena cava syndrome that occurred a few hours after insertion of an implantable cardioverter defibrillator through the right subclavian vein in a patient with previous dual chamber DDD pacemaker. The patient was successfully treated with anticoagulant therapy showing a fast clinical and instrumental improvement.
Abstract: Left ventricular apical ballooning, also named tako-tsubo cardiomyopathy, is a syndrome characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes mimicking an acute myocardial infarction without significant stenosis on the coronary angiogram. Although the aetiology remains unknown, several reports have found that preceding psychological stress could act as a trigger. This report describes a case of tako-tsubo-like left ventricular apical ballooning in a patient with "soft" atherosclerotic plaque at the middle portion of the left anterior descending coronary artery.
Abstract: Postoperative brain damage is a major sequela of cardiovascular surgery. Different methods-such as transcranial Doppler imaging, carotid echography, and fluorescein angiography-can be used to monitor cerebral blood flow, but they present specific limitations.High-resolution color Doppler imaging of the ophthalmic artery is a useful, noninvasive, and inexpensive technique for the evaluation of cerebral blood flow during cardiac surgery; signal changes can represent hypoperfusion of cerebral vessels and can thereby indicate inadequate cerebral perfusion during cardiac surgery, especially surgery of the aortic arch.
Abstract: BACKGROUND: Prior studies demonstrated that kinetics of oxygen uptake (KVO(2)) at the onset of exercise is delayed in patients with ischemic left ventricular dysfunction (LVD), since it reflects a slower cardiac output increase. Given the myocardial contractile reserve elicited by endogenous catecholamines during exercise, it may be speculated that patients with a significant amount of myocardial viability (MV) could show a faster KVO(2) at the onset of exercise attributable to a faster increase in stroke volume compared to patients without MV. OBJECTIVES: To demonstrate a relationship between contractile reserve detected by low-dose dobutamine Echocardiography (LDDE) and KVO(2) obtained during cardiopulmonary testing in patients with ischemic LVD. METHODS: Forty-one consecutive patients (62.5+/-10.1 years) with ischemic LVD underwent LDDE and constant work rate exercise with KVO(2) determination. The time constant for VO(2) (tau) was determined by a curve fitting breath-by-breath data. Ten healthy subjects served as control group (59.5+/-13.4 years). RESULTS: LDDE identified contractile reserve in 20 (48%) subjects. Patients without MV detected by LDDE showed a significantly longer tau compared to patients with MV and to healthy subjects (p=0.03 and p=0.01, respectively). Sensitivity, specificity, positive and negative predictive value of tau in detecting MV were 90%, 95%, 95% and 91%, respectively. Moreover, the percentage reduction of LV wall motion score index detected at LDDE was significantly related to KVO(2) (r=0.71, p<0.01) CONCLUSIONS: Our data suggest that KVO(2) represents a reasonable initial approach to estimate presence of MV in patients with ischemic LVD.
Abstract: Background: Stentless valves have been demonstrated excellent hemodynamic performances favoring the recovery of left ventricular function and the ventricular hypertrophy regression. The aim of the study was to evaluate the early hemodynamic performance of the Shelhigh SuperStentless aortic valve (AV). Methods: Between July 2003 and June 2005, 35 patients (18 females; age 70.8 +/- 11.7 years, range: 22-85) underwent AV replacement with the Shelhigh SuperStentless bioprostheses. Most recurrent etiology was senile degeneration in 25 (71%) patients and 24 (69%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant coronary artery bypass grafting was performed in nine patients (25.7%) and mitral valve surgery in two patients (5.7%). Doppler echocardiography was performed before surgery, at six-month and one-year follow-up. Results: There were no hospital deaths and no valve-related perioperative complications. During one-year follow-up, no endocarditis or thromboembolic events were registered, no cases of structural dysfunction or valve thrombosis were noted. Mean and peak transvalvular gradients significantly decrease after AV replacement, with an evident reduction to approximately 50% of the preoperative values at six months. A 20% reduction was also observed for left ventricular mass (LVM) index at six months, with a further regression at one year. Correspondingly, significant increases in effective orifice area (EOA) and indexed EOA were determined after surgery (0.87 +/- 0.14 versus 1.84 +/- 0.29 cm(2) and 0.54 +/- 0.19 versus 1.05 +/- 0.20 cm(2)/m(2), respectively). Valve prosthesis-patient mismatch was moderate in five patients and severe in one case. Conclusions: Shelhigh SuperStentless AV provided good and encouraging hemodynamic results. Long-term follow-up is necessary to evaluate late hemodynamic performance and durability of this stentless bioprosthesis.
Abstract: Tako-tsubo cardiomyopathy is an enigmatic syndrome characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes induced by physical or emotional stress. We describe the first case of this syndrome associated with acute mitral regurgitation due to bacterial endocarditis: the reversible ventricular dysfunction might have been induced by altered catecholamine dynamics due to the pulmonary edema.
Abstract: BACKGROUND: Availability of a telematic system of electrocardiogram (ECG) transmission may improve the management of ST-elevation myocardial infarction (STEMI), by reducing time to treatment. The aim of this study was to show the effectiveness of telephone transmission of ECG in improving quality of care for patients with acute STEMI. METHODS: Since January 1, 2003, we activated a management program of STEMI in healthcare district of Varese, located in the North-West of Lombardy (Italy), comprising one fourth-level hospital, equipped with a cath lab on call 24/24 h for primary angioplasty since 1993 and cardiac surgery, and 2 community hospitals, placed in a mountain area approximately 30 km far from Varese. The emergency medical system (EMS) transport was activated 24/24 h and has 15 basic life support (BLS) ambulances with trained nurse staff and 2 mobile units with medical staff, all of them equipped with semiautomatic defibrillator Lifepack 12, enabling a GSM telephone transmission of a 12-lead ECG, coupled with 3-lead continuous rhythm recording and clinical data, if necessary. The ECGs were transmitted to a core unit placed in the coronary care unit (CCU) of the Hospital di Circolo of Varese, directly connected with the EMS core unit. RESULTS: From January 2003 to August 2005, a total of 2063 ECGs were transmitted, 538 of them (26%) recorded by EMS ambulances. Of 144 ECGs (7%) showing a persistent ST-elevation suggesting an acute STEMI (group A), 112 subjects underwent reperfusion: 73 were treated with angioplasty and 39 by lysis alone. By comparing data of group A with a group of 256 patients (180 reperfused) with acute STEMI, admitted to our hospital in the same period without ECG teletransmission (group B), we observed no statistical difference in mortality and reperfusion rates but a significative reduction in the pre-hospital and in-hospital times in group A patients treated by primary angioplasty and thrombolysis. CONCLUSIONS: Our study confirms previous results in that an early availability of a 12-lead ECG, transmitted from peripheral community hospitals and BLS ambulances, is able to reduce time to management of patients with an acute STEMI, thus improving quality of decision-making and treatment.
Abstract: BACKGROUND: Zofenopril has beneficial effects in acute myocardial infarction, and improves the functional recovery after ischemia and reperfusion. Aim of the study: The aim of this study was to investigate the cardioprotective effects of zofenopril, when added to a standard cardioplegic solution or when orally administered as pretreatment. METHODS: A Langendorff model for isolated rat hearts was employed: three groups of eight hearts each were used, respectively, with plain St. Thomas cardioplegia as control (group A and C), and the same solution added with 12.5 mg of zofenopril (group B). The third group (C) was pretreated for 7days with oral administration of zofenopril (6.5 mg/day). The hearts had a baseline perfusion for 30 minutes with Krebs-Henseleit solution at 37 degrees C, cardioplegia administration for 3 minutes, then 30 minutes of ischemia without any perfusion, and finally 30 minutes of reperfusion with Krebs-Henseleit solution at 37 degrees C. RESULTS: Left ventricle developed pressure was significantly higher in the reperfusion period only in the pretreated group (group C) with respect to groups A and B (p = 0.016). Similar results were obtained regarding dP/dt curves (p = 0.020). No differences were demonstrated between groups for cellular viability expressed as creatine phospho-kinase (p = ns) and lactate dehydrogenase release (p = ns). CONCLUSIONS: Zofenopril as oral pretreatment showed protective effects in an isolated model of cardioplegic arrest, although improvements in myocardial viability (enzymatic release) could not be demonstrated. Further experimental and clinical evaluations are necessary to assess the direct cardioprotective effect of zofenopril, modifying the length of treatment and the dosage of the drug.
Abstract: Dissection of the interventricular septum (IVS) is a rare condition, which can uncommonly complicate an acute myocardial infarction (AMI). We describe a case of unruptured IVS dissection observed 16 days after 2 close episodes of AMI. The diagnosis was made by transthoracic echocardiography. An echo-free space within the thickness of IVS, extended from the apex to the mid-portion, for a total length of about 30 mm was evident. The careful examination of the left ventricle did not reveal any discontinuity of the myocardial wall. The stable clinical condition, the absence of flow within the dissection, the demonstration of its favourable evolution during the hospitalisation and the characteristics of the underlying coronary disease (left anterior descending artery occlusion without myocardial viability) led to the decision of avoiding surgery. The predischarge contrast echocardiographic examination (Levovist) showed clearly the border of the infarcted zone and demonstrated an area reduction and echogenicity increase of the neocavitation, with partially organised thrombi. The patient recovered uneventfully and was discharged on medical therapy with a clinical and echocardiographic follow-up program. We believe that for IVS hemorrhagic dissection a nonsurgical option can be proposed; surgery should only be considered for myocardial revascularization when indicated. A close echocardiographic follow-up is mandatory.
Abstract: BACKGROUND AND AIM OF THE STUDY: The optimal management of chronic ischemic mitral regurgitation (CIMR) remains controversial. Herein, the authors reviewed the past 10 years of their experience to compare the long-term results of mitral valve repair with prosthetic replacement. METHODS: Between January 1993 and January 2003, 102 patients (mean age 67.8 years; range: 51-80 years) with a preoperative diagnosis of CIMR, underwent mitral valve repair (n = 61; 59.8%) or prosthetic replacement (n = 41; 40.2%), along with myocardial revascularization (2.5 +/- 1.0 distal anastomoses per patients, internal thoracic artery used in 78.5%). A Carpentier Classic ring was always used in the repair procedures. The two groups were homogeneous for preoperative characteristics and comorbidities. RESULTS: Total operative mortality was 7.8% (repair 8.2%; prosthesis 7.3%; p = NS). The five-year actuarial survival (operative mortality included) was 66.6 +/- 7.4% for repair and 73.4 +/- 8.7% for prosthesis (p = NS). Cox multivariate analysis showed as independent risk factor for late survival a preoperative left ventricular ejection fraction (LVEF) < or = 30% (RR 3.91; 95% CI = 1.47-10.38) and a preoperative pulmonary artery pressure (PAP) > or = 35 mumHg (RR 2.74; 95% CI = 1.07-7.02), while the type of mitral procedure was not significant. Patients with annular dilation as a mechanism of regurgitation were significant more likely to undergo repair rather than receive a prosthesis. Their preoperative LVEF and PAP were significantly worse than patients who had altered leaflet motion as a regurgitation mechanism. CONCLUSION: Prosthetic mitral replacement and valve repair offer very similar results for CIMR. When a perfect repair is not easily feasible, cardiac surgeons should not hesitate to perform mitral valve replacement, as it is an excellent alternative therapy, though long-term outcome is mainly dependent on preoperative condition.
Abstract: This report describes the case of a 39-year-old man, admitted for the occasional finding of left ventricular, irregular and pedicled mass. Because of the elevated risk of thromboembolism, cardiac surgery was performed with complete removal of the mass. Histologic examination showed it to be composed entirely of thrombotic material. Additional laboratory data revealed the simultaneous presence of two thrombophilic disorders: antiphospholipid syndrome and hyperhomocysteinemia. Screening laboratory evaluation for hypercoagulable states is recommended in similar cases.
