Showing papers in "Journal of Cardiovascular Medicine in 2009"

Aetiological diagnosis in acute and recurrent pericarditis: when and how.

Abstract: The cause of acute and recurrent pericarditis is often a major concern for the clinicians in clinical practice. Several possible causes of pericarditis can be listed, as the pericardium may be involved in a large number of systemic disorders or may be diseased, as an isolated process. The reported diagnostic yield of extensive laboratory evaluation and pericardiocentesis is low in the absence of cardiac tamponade or suspected neoplastic, tuberculous, and purulent pericarditis. Patients with pericarditis can be safely managed on an outpatient basis without a thorough diagnostic evaluation unless a specific cause is suspected or the patient has high-risk features, or both. A targeted aetiological search should be directed to the most common cause on the basis of the clinical background, epidemiological issues or specific presentations. In developed countries the clinicians should rule out neoplastic, tuberculous, and purulent pericarditis, as well as pericarditis related to a systemic disease.

Rationale and design of a trial evaluating the effects of losartan vs. nebivolol vs. the association of both on the progression of aortic root dilation in Marfan syndrome with FBN1 gene mutations.

Abstract: BackgroundThe major clinical problem of Marfan syndrome (MFS) is the aortic root aneurysm, with risk of dissection when the root diameter approximates 5 cm. In MFS, a key molecule, transforming growth factor-β (TGF-β), normally bound to the extracellular matrix, is free and activated. In an experime

The association of bicuspid aortic valve disease with asymmetric dilatation of the tubular ascending aorta: identification of a definite syndrome.

Abstract: Introduction Bicuspid aortic valve (BAV), due to its high prevalence in the general population and the high inherent rate of aortic valve and ascending aorta complications, has to be looked at as a socially relevant disease [1]. Recent scientific literature has been focusing on several aspects of this disease, including its pathogenesis, so far not clearly elucidated, its clinical implications in terms of screening and follow-up, and its surgical implications [2]. A specific aspect of the BAV question that we aim to address in the present paper is the heterogeneous nature of the anatomoclinical forms that this disease can assume, yielding in turn specific cardiologic and surgical implications for treatment. BAV patients can be either asymptomatic with a nonsignificantly regurgitant valve and yet an aneurismal aortic root requiring surgical repair, or also referred for severe valve stenosis yet with a normal aortic root, and all the possible ‘in-between pictures’ can occur in everyday practice. In particular, we will focus on the evidence from both the most recent scientific literature and our experience over more than 10 years with the research on BAV disease, aiming to identify within this heterogeneity a more common anatomo-clinical form, that may be defined as a syndrome, in as much as it is characterized by a definite and constant pattern of aortic valve and ascending aorta involvement.

Does combined mitral valve surgery improve survival when compared to revascularization alone in patients with ischemic mitral regurgitation? A meta-analysis on 2479 patients.

Abstract: ObjectivesOptimal treatment of significant (≥2+ grade) ischemic mitral regurgitation remains controversial, and the impact of mitral valve surgery (MVS) at the time of coronary artery bypass grafting (CABG) on early and late results has to be still clarified.MethodsA systematic literature search for

Speckle-tracking-derived strain and strain-rate analysis: a technique for the evaluation of early alterations in right ventricle systolic function in patients with systemic sclerosis and normal pulmonary artery pressure.

Abstract: Background and aim Systemic sclerosis is associated with pulmonary artery hypertension. Speckle-tracking-derived strain and strain rate may be a diagnostic tool to detect early changes in right ventricular function, before pulmonary artery hypertension development. Our aim was to assess whether speckle-tracking-derived strain and strain-rate parameters may detect right ventricular early alterations in patients with systemic sclerosis with normal pulmonary systolic artery pressure (PAP). Methods Seventeen asymptomatic patients with systemic sclerosis and 22 controls were enrolled. A complete two-dimensional echo with speckle-tracking-derived longitudinal strain and strain rate of the basal right ventricular free wall and interventricular septum was performed. Results Median age was 56 years (43.8-71.5) in the systemic sclerosis group and 48.5 years (32-56.5) in the control group. No differences in conventional left ventricular parameters, tissue Doppler indexes, or in tricuspid annular plane systolic excursion were found. Patients with systemic sclerosis had higher levels of peak tricuspid regurgitation velocity and less respiratory collapse in the inferior vena cava. There were no differences in the speckle-tracking-derived strain and strain-rate parameters measured at the level of the basal interventricular septum and in the strain values measured at the level of the basal lateral right ventricular free wall. Nevertheless, a significant increase of the longitudinal strain rate measured at the basal lateral free wall of the right ventricle was found in patients with systemic sclerosis when compared with controls [-5.5 (-6.4--2.6)/s vs. -1.8 (-3.9--1.4)/s; P = 0.014]. Conclusion Speckle-tracking-derived longitudinal strain rate is useful to detect early right ventricular function changes in patients with systemic sclerosis with normal pulmonary systolic artery pressure levels. This alteration may preclude pulmonary artery hypertension development and reflect an adaptive response to higher levels of pulmonary systolic artery pressure.

Two-year multicomprehensive secondary prevention program: favorable effects on cardiovascular functional capacity and coronary risk profile after acute myocardial infarction.

Abstract: BackgroundCardiac rehabilitation includes interventions aimed at facilitating physical, psychological and emotional recovery following the acute phase of myocardial infarction (AMI). To date, optimal cardiac rehabilitation program duration and frequency of patient contact has yet to be identified.Ob

Acute inferior myocardial infarction due to cannabis smoking in a young man.

Abstract: Cannabis smoking, which has euphoric effects, is consistently increasing in Europe. Smoking cannabis is a rare trigger of acute myocardial infarction (MI) by inducing coronary artery spasm. Some cases who have thrombus formation in acute coronary artery and no serious atherosclerotic lesions have been reported in the literature. These cases had involved the left coronary artery. Although some cases were reported with MI after cannabis smoking, only two case reports with inferior MI after cannabis smoking were reported in the literature. The present report is of a young male patient who was affected by acute inferior MI half an hour after cannabis smoking.

Adverse reactions after the use of sulphur hexafluoride (SonoVue) echo contrast agent.

Abstract: The aim of the present study was to analyse the adverse effects of SonoVue echo contrast in a consecutive series of 352 cardiac patients during a 4-year period. During 352 consecutive cardiac SonoVue studies, seven patients (2.0%) experienced adverse effects. Four patients (1.1%) had mild allergic reactions causing skin erythema and mild sinus tachycardia, and three patients (0.9%) experienced a severe allergic reaction resulting in (nonfatal) shock. The reported incidence of adverse effects of SonoVue echo contrast in this consecutive series of cardiac patients seems markedly higher than those reported in a company postmarketing analysis.

Risk of arrhythmias in myotonic dystrophy: trial design of the RAMYD study

Abstract: Objective Myotonic dystrophy type 1 (DM1) is the most frequent muscular dystrophy in adults. DM1 is a multisystem disorder also affecting the heart with an increased incidence of sudden death, which has been explained with the common impairment of the conduction system often requiring pacemaker implantation; however, the occurrence of sudden death despite pacemaker implantation and the observation of major ventricular arrhythmias generated the hypothesis that ventricular arrhythmias may play a causal role as well. The aim of the study was to assess the 2-year cumulative incidence and the value of noninvasive and invasive findings as predictive factors for sudden death, resuscitated cardiac arrest, ventricular fibrillation, sustained ventricular tachycardia and severe sinus dysfunction or high-degree atrioventricular block. Methods/design More than 500 DM1 patients will be evaluated at baseline with a clinical interview, 12-lead ECG, 24-h ECG and echocardiogram. Conventional and nonconventional indications to electrophysiological study, pacemaker, implantable cardioverter defibrillator or loop recorder implantation have been developed. In the case of an indication to electrophysiological study, pacemaker, implantable cardioverter defibrillator or loop recorder implant at baseline or at follow-up, the patient will be referred for the procedure. At the end of 2-year follow-up, all candidate prognostic factors will be tested for their association with the endpoints. Trial registration ClinicalTrials.gov ID NCT00127582. Conclusion The available evidence supports the hypothesis that both bradyarrhythmias and tachyarrhythmias may cause sudden death in DM1, but the course of cardiac disease in DM1 is still unclear. We expect that this large, prospective, multicenter study will provide evidence to improve diagnostic and therapeutic strategies in DM1.

D-dimers are not always elevated in patients with acute aortic dissection.

Abstract: In patients with acute aortic dissection, an early diagnosis is essential to anticipate aortic rupture, cardiac tamponade, organ ischemia and improve surgical results. A specific blood laboratory marker able to rule out the presence of aortic dissection has not been identified yet. Recently, several studies suggested using D-dimers as a negative predicting test to rule out diagnosis of acute aortic dissection in patients presenting with chest pain. In 61 patients with confirmed aortic dissection, preoperative D-dimers were assayed and correlated with time from symptom onset and extension of the false lumen dissection (according with De Bakey classification). Abnormal D-dimers values were considered those being greater than 400 microg/l. D-dimers values were above 400 microg/l in 50 patients (82%) and below 400 microg/l in 11 patients (18%). There was no correlation between preoperative D-dimers values and time from symptoms onset (r = -0.232; P = 0.1). We found that D-dimers are not always elevated in patients presenting with acute aortic dissection. Given the potential devastating effects of denying the diagnosis of acute aortic dissection with consequent delay of adequate treatment, a word of caution regarding the negative predictive value of D-dimer test in the diagnosis of aortic dissection seems warranted.

Natural history of dilated cardiomyopathy: from asymptomatic left ventricular dysfunction to heart failure--a subgroup analysis from the Trieste Cardiomyopathy Registry.

Abstract: Background Few data are available in the literature regarding the characteristics and prognosis of asymptomatic patients with idiopathic dilated cardiomyopathy (DCM). Aim To determine the frequency with which patients affected by DCM are diagnosed in the asymptomatic state as well as to evaluate the natural history of such patients and the factors influencing their outcome. Moreover, we sought to compare the outcome of asymptomatic patients with that of patients with signs of overt heart failure at the time of first evaluation. Methods and results We analyzed the data of 747 patients with DCM enlisted in the Heart Muscle Disease Registry of Trieste from 1978 to 2007. We divided our population into four groups; group 1 comprised 118 asymptomatic [New York Heart Association (NYHA) I] patients without a history of congestive symptoms (16%), group 2 comprised 102 asymptomatic (NYHA I) patients (14%) with a positive anamnesis for heart failure stabilized in medical therapy, group 3 comprised 327 patients (44%) with signs of mild heart failure (NYHA II) and group 4 comprised 200 patients (26%) in NYHA III–IV. During the follow-up of 112 ± 63 months, 46 (21%) of 220 asymptomatic patients with DCM died or underwent heart transplantation. By Cox proportional model, left ventricular ejection fraction of 30% or less was a unique independent predictor either for death/heart transplantation (hazard ratio 3.15, 95% confidence interval 1.5–6.7, P = 0.003) or for sudden death/major ventricular arrhythmias (hazard ratio 3.9, 95% confidence interval 1.7–9.3, P = 0.002). Patients from group 1 had a trend for a better outcome with respect to those from group 2 (P = 0.06). In comparison with the asymptomatic patients, those with signs of overt heart failure at baseline had a worse prognosis. Conclusion The proportion of asymptomatic patients with DCM at the moment of first evaluation at our center is significant (30%). Among them, those without a previous history of heart failure had a less advanced disease and a trend for a better long-term outcome on optimal medical treatment. Therefore, early diagnosis may offer better long-term quality of life and even better survival. Further studies on larger populations are indicated.

Individual pathogens, pathogen burden, and markers of subclinical atherosclerosis: the Multi-Ethnic Study of Atherosclerosis

Abstract: MethodsWe examined the cross-sectional relationships of subclinical atherosclerosis – expressed by carotid intimal–medial thickness and coronary calcification – with antibodies to Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, herpes simplex virus, hepatitis A virus, and pathogen burden

Common femoral artery access techniques: a review.

Abstract: The increasing burden of coronary artery disease has resulted in more percutaneous coronary artery interventions. The common femoral artery remains the most widely accepted site for percutaneous coronary artery access. Local access site, vascular complications remain a considerable source of morbidity during common femoral arterial puncture. This has prompted angiographers, over the years, to define various reliable landmarks and techniques to access the common femoral artery, in an attempt to minimize and avoid complications. In this discourse, we discuss the various techniques of obtaining common femoral arterial access, with their relative benefits and disadvantages. The literature supporting the various palpatory or radiographic landmark-guided methods is reviewed. There are limited data on the superiority of any individual method.

Bacteriology of infected extracted pacemaker and ICD leads.

Abstract: Introduction Pacemaker and implantable cardioverter defibrillator infections, when not treated, lead to serious consequences. The aim is to identify the prevalent strains of the responsible bacteria to guide an effective therapy. Methods Between May 2003 and April 2008, 118 leads were extracted from 61 patients, with chronic draining sinus, pocket infection, pacemaker endocarditis, or sepsis. Following extraction, samples of the leads underwent cultural and antibiogram examination. Results Staphylococcus epidermidis was the most frequently isolated bacterial strain (37.7%), followed by Gram-positive flora (16.1%), Staphylococcus aureus (14.3%), Candida parapsilosis (5.4%), Staphylococcus schleiferi (5.4%), Corynebacterium species, and Staphylococcus hominis (3.6%). Cultures were negative in 14.3% of the samples. Retained sensitivity to antibiotics were reported as follows: teicoplanin/vancomycin 100%, doxicyclin 96%, amikacin 94%, piperacillin-tazobactam 58%, cotrimoxazole 78%, gentamycin 65%, quinolones 47%, rifampicin 44%, cephalosporins 25%, and oxacillin 25%. Within staphylococci, involved in about 60% of the infections, S. hominis and S. epidermidis showed the highest antibiotic resistance. In case of sepsis, sensitivity was retained for glycopeptides and amikacin (about 100%), and to a lower degree for doxicyclin (80%). Arbitrarily stratifying into recent ( 3 months) infections, an increase in time prior to referral for lead extraction was associated with a significant increase in antibiotic resistance. Conclusion Bacteria associated with pacemaker and implantable cardioverter defibrillator-related infections, staphylococci in about 60% of the cases, show poor susceptibility to antibiotics, presenting three out of four methicillin-resistant features. Therefore, systemic antibiotics, mainly glycopeptides, must not be delayed awaiting the complete removal of the implanted system.

Left ventricular trabeculae: quantification in different cardiac diseases and impact on left ventricular morphological and functional parameters assessed with cardiac magnetic resonance.

Abstract: OBJECTIVES Left ventricle trabeculae (LVT) are frequently seen in different cardiac diseases. Normal reference values of LVT in different cardiac conditions are not known. The aim of the study was to quantify with cardiac magnetic resonance (CMR), LVT mass (LVTM) and LVTM percentage (LVTM%) in different heart diseases and to evaluate their influence on left ventricular morphological and functional parameters. METHODS Fifty-nine patients (14 controls, 17 ischemic cardiomyopathy, 15 nonischemic dilated cardiomyopathy, 7 valvular heart disease and 6 with left ventricle hypertrophy) were enrolled. Cine-MR images were acquired with steady-state free-precession sequence in a short-axis view. LVTM was calculated as the difference between LVM excluding/including trabecuale from the blood cavity. LVTM% was calculated as the percentage of the whole left ventricle mass excluding trabeculae from the blood cavity. RESULTS Mean age was 47.60 +/- 22.03 years; male 62.7%. Mean LVTM was of 33.38 +/- 16.1 g with mean LVTM% of 19.22 +/- 6.5%. Significant differences between groups for both parameters with P values of 0.02 were obtained. Nonischemic dilated cardiomyopathy showed the highest degree of LVTM (44.73 +/- 16.0 g) and LVTM% (23.26 +/- 6%). Significant differences were noted in left ventricular morphological and functional parameters with inclusion/exclusion of LVT in the myocardial mass. CONCLUSIONS Reference values and differences of LVTM and LVTM% in various cardiac conditions are given for the first time. Quantification of these parameters with CMR may be clinically useful in the differential diagnosis between left ventricular noncompaction and other cardiac diseases. Exclusion of LVT from myocardium alters left ventricular morphological and functional parameters, which have significant clinical importance.

Hormone replacement therapy and cardioprotection: a new dawn? A statement of the Study Group on Cardiovascular Disease in Women of the Italian Society of Cardiology on hormone replacement therapy in postmenopausal women.

Abstract: Cardiovascular disease is the leading cause of death in women in Western countries. Despite preventive strategies, in the past decades the incidence of cardiovascular events has shown a decline in men but a rise in women, matching the growth of the population of postmenopausal women. Several epidemiological findings suggest the causative pathophysiological role of ovarian hormone deficiency in the development of cardiovascular disease in women. Observational and randomized studies have suggested that hormone replacement therapy in early postmenopause could be beneficial from a cardiovascular point of view. Conversely, aging, time since menopause and presence of cardiovascular risk factors or cardiovascular disease may decrease its efficacy and increase the risk of cardiovascular events. It is plausible that the unfavorable effects of the estrogen/progestin combination used in the randomized studies are not related to the hormone preparation per se but rather to the use of hormones in the less receptive group of women, older and with cardiovascular risk factors. Clinical judgment, choice of the right dose and estrogen/progestin combination are of pivotal importance to maximize the beneficial effect of estrogen replacement therapy/hormone replacement therapy, especially if given within a reasonable time after the menopause to women who need the therapy for the relief of menopausal symptoms.

Does echocardiography play a role in the clinical diagnosis of congenital absence of pericardium? A case presentation and a systematic review.

Abstract: Congenital absence of pericardium is an uncommon cardiac defect with variable clinical presentations. The detection of this malformation is clinically relevant because of potential complications such as fatal myocardial strangulation, myocardial ischemia and sudden death. Physical examination, chest radiograph and ECG are not helpful for the diagnosis. Echocardiography may accurately identify abnormalities in myocardial wall motion and in cardiac silhouette that may strongly suggest the diagnosis that is confirmed by magnetic resonance imaging (MRI) or computed tomography scan. A case presentation and a review of the literature with emphasis on the role of echocardiography are presented.

Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group.

Abstract: Background Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia that in almost 50% of cases is followed by sudden death. The increasing frequency of SCAD diagnosis may reflect the widespread use of coronary angiography and percutaneous coronary interventions in acute coronary syndromes (ACS). The incidence of SCAD is estimated between 0.1 and 0.28% of all ACS or sudden deaths evaluated by angiography or by anatomical examination, respectively. Most published data available so far deal with single case reports and probably the real incidence of this disease is underestimated. Some predisposing conditions to SCAD are well known and include Marfan syndrome, pregnancy and peripartum state, drug abuse and some anatomical abnormalities of the coronary arteries like aneurysms and severe kinking. The most appropriate therapeutic approach to SCAD is still controversial and decision making is often based on the clinical presentation, extent of dissection and amount of ischemic myocardium. Objectives and methods The purpose of this multicenter prospective registry, named DISCOVERY (DISsection of COronary arteries: Veneto and Emilia RegistrY), with a case-control group is to try to assess the role of SCAD in the pathogenesis of ACS. The primary endpoint is the occurrence of major adverse cardiovascular events related to the therapeutic strategy in the acute phase and in the mid-term follow-up. The secondary endpoints are the estimation of the prevalence of SCAD in the pathogenesis of ACS, the association or disassociation of SCAD with presumptive predisposing factors, the appreciation of the timing and extent of multivessel involvement when present, the occurrence of vascular and ocular comorbidities (i.e. carotid dissection and ocular lens abnormalities), the evaluation of the immediate success and the mid-term outcome of percutaneous coronary interventions and the definition of the role of intravascular ultrasound in diagnosis and treatment of SCAD. The enrollment of approximately 50 patients with SCAD is planned. A planned control group of patients of comparable age, sex and clinical presentation will allow us to identify potential peculiar or specific aspects of SCAD in any phase of the disease. Conclusion The DISCOVERY multicenter registry, with a case-control group, is the first large prospective study aimed at assessing the role of SCAD in the pathogenesis of ACS and at identifying the role of different therapeutic strategies in this unusual, multifaceted and probably underestimated pathologic condition.

Heartmate II axial-flow left ventricular assist system: management, clinical review and personal experience.

Abstract: Objectives The excellent results with left ventricular assist devices (LVADs) have revolutionized the treatment options for end-stage heart failure. The use of pulsatile devices is associated with significant comorbidity and limited durability. The axial-flow HeartMate II LVAD represents the new generation of devices. The clinical use of this pump resulted in superior outcomes. We review the HeartMate II technology, management, clinical usage and our experience. Methods Between 3/2002 and 12/2008, 18 transplantable adult patients were supported on long-term HeartMate II LVAD at our institution (13 men, age 52 +/- 8.4 years, range: 31-64 years). Primary indications were: ischemic cardiomyopathy (CMP) (n = 13), idiopathic CMP (n = 5). All patients were in New York Heart Association (NYHA) Class IV heart failure. None of patients had prior open-heart surgery. Implantation via cannulation of the left ventricular apex and the ascending aorta was always elective. Results Mean support time was 217 +/- 212.3 days (range: 1-665 days). Early (30-day) mortality was 27.7% (five patients) with multiple organ failure and sepsis as main causes of death. Bleeding requiring reoperation occurred in six (33.3%) cases. Cerebral hemorrhage occurred in one patient. There were two driveline infections and no device failure. Twelve (66.6%) patients were successfully discharged home. Overall nine patients (50%) were transplanted and two patients are actually waiting for a suitable organ (n = 2 patients discharged home and n = 1 patient in hospital). At latest, follow-up survival rate after heart transplantation is 66.6% (six patients). Conclusion Long-term HeartMate II LVAD provides good mid-term, long-term results. This new technology requires delicate management. Functional status and quality of life greatly improve in patients who survive the perioperative period.

Cardiac hemangioma in the left ventricle and brief review of the literature.

Abstract: Cardiac hemangiomas are very rare benign cardiac tumors. They can present at any age and clinical presentation varies according to location and size. Most common symptoms include shortness of breath, palpitations, atypical chest pain and arrhythmia. The natural history of these tumors is unpredictable. They can regress, cease growing or proliferate over time. Diagnosis is usually made with echocardiography and surgical resection is the treatment of choice. Follow-up is recommended to identify any recurrence. We report a case of a 38-year-old man who presented with fatigue and palpitations. Echocardiography revealed a mobile spherical mass within the left ventricle, whereas left ventriculography showed an intracavity-filling defect without any tumor blushing. The tumor was removed surgically through the left atrium. It was a smooth oval nodule with a pedicle that was attached to the top of a papillary muscle. Microscopy revealed the presence of numerous vessels within fibrous tissue that ranged from lobules of capillary hemangioma to large thin-walled cavernous vessels, compatible with a hemangioma of mixed capillary-cavernous type. The patient had an uneventful postoperative course and recovered quickly.

Atypical Takotsubo syndrome during anagrelide therapy.

Abstract: Anagrelide is a phosphodiesterase III inhibitor utilized in the treatment of essential thrombocythemia. Anagrelide can be responsible for positive inotropic and chonotropic activity of the cardiovascular system. Moreover, it can induce vasospam directly on the epicardial coronary arteries. In the literature, it is well reported that this inhibitor can determine serious cardiovascular side effects, including congestive heart failure, arrhythmia and acute coronary syndrome. We describe the case of a 75-year-old woman who developed a mid-ventricular Takotsubo syndrome while on anagrelide therapy. Takotsubo cardiomyopathy, also known as left ventricular ballooning syndrome, is characterized by a reversible ventricular contractile dysfunction with akinesis and expansion of apical segments and hyperkinesis of the basal segments. Recently, atypical cases with akinesia and dilation of mid-ventricular segment and hypercontraction of the apical segments, also called mid-ventricular and inverted Takotsubo syndrome, have been described. Even though the pathogenesis of Takotsubo syndrome is poorly understood, several mechanisms have been proposed, including catecholamine-induced myocardial stunning, and ischemia-mediated stunning due to multivessel epicardial or microvascular spasm. We think that in our case, the adverse response of anagrelide therapy was determined, by accumulated dosage of the drug, through an intensive inotropic stimulation and a sympathetic hyperactivation in a vulnerable myocardium. To our knowledge, this is one of the first reports of an association between anagrelide therapy and Takotsubo cardiomyopathy.

Tako-tsubo cardiomyopathy following electroconvulsive therapy.

Abstract: A 70-year-old woman with extensive psychiatric history, including depression and bipolar disorder, and past medical history of mitral valve prolapse repair (3 years ago) was brought in from the psychiatry ward to the emergency department for evaluation of ECG changes following electroconvulsive therapy (ECT). ECG done after the procedure showed ST elevations in V2-V3 and new T-wave inversions in the precordial leads. Troponin level was 0.23 ng/ml. An echocardiogram revealed apical akinesis with segmental wall motion abnormalities and a decreased ejection fraction of 30-35%. Cardiac catheterization revealed clean coronaries. A repeat echocardiogram 6 weeks after the event showed a normal ejection fraction. A diagnosis of tako-tsubo cardiomyopathy was made. ECT causes a significant increase in bigeminy, trigeminy, and supraventricular tachycardia. ECT is associated with a low mortality rate; in the range of 0.01-0.1% and 75% of these are attributable to cardiovascular causes. To our knowledge, this is the first reported case of tako-tsubo syndrome immediately following electroconvulsive therapy.

Novel anticoagulants in clinical development: focus on factor Xa and direct thrombin inhibitors.

Abstract: Vitamin K antagonists are the mainstay in the prevention and treatment of thromboembolic diseases. Although effective under optimal conditions, several drawbacks are imminent to the long-term application of these drugs due to their narrow therapeutic window, interactions with other drugs as well as the need for regular monitoring and the risk of a recurrent event versus the risk of bleeding. To overcome these downsides, novel anticoagulants are being developed; in contrast to vitamin K antagonists, these novel agents specifically and selectively block central elements of the coagulation cascade. Several clinical trials have demonstrated the efficacy and safety of selective FXa inhibitors (such as fondaparinux, rivaroxaban, apixaban) and direct thrombin inhibitors (such as lepirudin, bivalirudin, dabigatran etexilate) in the treatment of typical indications for conventional vitamin K antagonists, in particular, the prevention and treatment of venous thromboembolism. This review summarizes the results and designs of recently published and ongoing clinical trials of novel anticoagulants.

Flecainide as first-line treatment for supraventricular tachycardia in newborns

Abstract: BackgroundFlecainide for the treatment of supraventricular tachycardia (SVT) in newborns is still controversial because of its potentially severe proarrhythmic effects.Methods and resultsBetween January 2004 and December 2006, we used flecainide to treat 20 consecutive newborns (15 males) with parox

Is steroid therapy enough to reverse complete atrioventricular block after percutaneous perimembranous ventricular septal defect closure

Abstract: Due to the close proximity of the perimembranous ventricular septal defect to the conduction system, complete atrioventricular block may occur after transcatheter closure in around 1-5% of cases. Some authors reported on successful use of steroids and aspirin in reversing complete atrioventricular heart block early after transcatheter closure of perimembranous ventricular septal defect using the Amplatzer membranous ventricular septal defect occluder. In this paper, we report a case of reappearance of complete atrioventricular block requiring a definitive pacemaker implantation after an initial successful reversal using both steroids and aspirin.

Ischemia and reperfusion-induced arrhythmias: role of hyperoxic preconditioning.

Abstract: Background Hyperoxic preconditioning is known to protect the heart against necrosis and contractile dysfunction, but protection against arrhythmias has not been well characterized. Objective The authors hypothesized that pre-exposure to normobaric hyperoxia (H) reduces ischemia and reperfusion-induced arrhythmias in isolated rat hearts. Methods Following 60 and 180 min of hyperoxia treatment, rat hearts were isolated immediately (H60 and H180) or 24 h afterward (H60/24 and H180/24), and subjected to 30 min of regional ischemia followed by 120 min of reperfusion. Occurrence, number, and duration of arrhythmias were analyzed during ischemia and reperfusion. In addition, cardiac infarct size was also assessed. Results Sixty and 180 min of breathing hyperoxic gas induced significant protection against severe ischemia and reperfusion-induced arrhythmias. Total number of premature ventricular beats was markedly attenuated by hyperoxia pre-exposure, especially in H60 and H180 groups. Duration of ventricular tachycardia and ventricular fibrillation was also affected by hyperoxia. Hyperoxia reduced the number of ventricular tachycardia episodes in ischemia and reperfusion phase. Accordingly, severity of arrhythmias (arrhythmia score) and infarct size were lower in hyperoxia-treated groups. The effects were more pronounced using hyperoxia immediately before harvesting the heart. Conclusion These results indicate that hyperoxic preconditioning attenuates ventricular ischemia and reperfusion-induced arrhythmias in isolated rat hearts, decreases cardiac infarct size, and improves postischemic heart function. The effects seem to depend on the time course after hyperoxia treatment.

Reliability of World Health Organization's Quality of Life-BREF versus Short Form 36 Health Survey questionnaires for assessment of quality of life in patients with coronary artery disease.

Abstract: ObjectiveThe objective of this study was to ascertain the reliability and predictive power of the World Health Organization's Quality of Life Questionnaire (WHOQOL-BREF) and Short Form 36 Health Survey questionnaire (SF-36) in coronary artery disease patients.MethodsBetween May and September 2006, p

Rationale and trial design of a randomized, controlled study on short-term psychotherapy after acute myocardial infarction: the STEP-IN-AMI trial (Short Term Psychotherapy in Acute Myocardial Infarction).

Abstract: Objective A number of previous studies addressed the effect of psychological interventions in patients after acute myocardial infarction (AMI), but it is not known whether psychotherapy might be beneficial after medical and interventional therapy of AMI. We designed a randomized, controlled study to assess the effects of a short-term psychotherapy (STP) on the clinical outcomes of patients who underwent an emergency percutaneous coronary intervention after AMI. Methods One hundred consecutive patients undergoing an emergency percutaneous coronary intervention will be randomized 1 week after AMI to medical therapy (control group, C group) or to medical therapy and STP (STP group). Clinical follow-up visits are scheduled at 6 months, 1 and 5 years, whereas psychometric tests (Self-Evaluation test, Modified Maastricht Questionnaire, Social Support Questionnaire, Recent Life Change Questionnaire, Beck Depression Inventory, the MacNew Heart Disease Health-Related Quality of Life Questionnaire, Type D Personality test) are scheduled 1 week after AMI and at 1 year. The primary outcome measures of the study are the cumulative incidence of new cardiological events (myocardial reinfarction, death, stroke, life-threatening ventricular arrhythmias, and recurrence of angina) and the occurrence of new medical disorders. Secondary outcome measures are the incidence of rehospitalizations due to cardiological problems, the prevalence of patients with New York Heart Association class > or = II, left ventricular function, as assessed by echocardiography, and mean score of psychometric tests in the two groups at follow-up. Conclusion Our study has been planned to obtain an insight into how a STP influences clinical outcomes after interventional and medical treatment of AMI.

A single-center experience of detecting coronary anomalies on 64-slice computed tomography.

Abstract: Background The detection of coronary anomalies is of major clinical significance. Coronary anomalies have been identified as a frequent cause of sudden death, particularly in young athletes. Multiple series have successfully demonstrated the ability of 64-slice computed tomography (CT) to identify coronary anomalies. However, the relationship of these anatomical variants with cardiac symptoms at presentation or cardiac events has not been well established. Methods Here, we report our experience over an approximately 3-year period identifying coronary anomalies with 64-slice CT coronary angiography. Results Coronary anomalies and myocardial bridging were found to be common among patients undergoing cardiac CT at our institution with an overall incidence of 8.9%. Cardiac symptoms in patients with isolated coronary anomalies or myocardial bridging detected on 64-slice CT coronary angiography included chest pain, shortness of breath, arm pain, palpitations and dizziness. A large percentage of patients with isolated coronary anomalies or myocardial bridging were noted to be asymptomatic (26.7%). The majority of patients reported chest pain (57.1%). Exertional symptoms were also relatively common (21.4%). A logistic regression analysis was conducted in which symptoms were used to predict patients with myocardial bridging as opposed to those with anomalies of origination and course, intrinsic coronary arterial anatomy or coronary termination, and no significant difference was found. Of the patients identified as having isolated coronary anomaly or bridging, 26% also underwent cardiac catheterization. In this group, all of the anomalies of origination and course (6/6) were identified by traditional angiography, whereas none of the patients (0/4) with bridging or anomalies of intrinsic coronary anatomy (right coronary artery aneurysm) were identified by angiography. No deaths or cardiac events were detected during the limited follow-up period. Conclusion Overall, 64-slice CT coronary angiography is a well suited imaging modality for detecting coronary anomalies and myocardial bridging. Further study in this area is necessary to better delineate the clinical significance of certain coronary anomalies and the incidence of clinical manifestations associated with each type of anomaly.

Left bundle branch block as an electrocardiographic pattern at presentation of patients with Tako-tsubo cardiomyopathy.

Abstract: BACKGROUND Tako-tsubo cardiomyopathy (TTC) is a recently described clinical condition that may mimic acute myocardial infarction. The presence or new onset of left bundle branch block (LBBB) is associated with adverse outcome in patients with acute myocardial infarction. OBJECTIVE We sought to assess the incidence, clinical profile, and outcome of patients with TTC and LBBB at presentation. METHODS AND RESULTS From July 2003 to December 2006, 84 consecutive patients met the diagnostic criteria for TTC. LBBB was present in eight (9%) patients at presentation. Patients with LBBB tended to be older (77 +/- 11 years versus 72 +/- 10 years; P=0.186), and with a more frequent, but not statistically significant, history of hypertension (75 versus 53%; P=0.227), and chronic renal failure (25 versus 8%, P=0.117). Moreover, patients with LBBB showed a higher peak creatine kinase-MB value (76 +/- 32 U/I versus 21 +/- 31 U/I; P=0.005), and a lower, but not significantly, baseline left ventricular ejection fraction (30 +/- 13% versus 36 +/- 9%; P=0.107), as compared with patients without LBBB. Follow-up length was 12 +/- 10 months. The mortality rate was higher in patients with LBBB as compared with those without (25 and 3%; P=0.005). However, at Cox analysis the only independent predictor of death was age (P=0.042). CONCLUSION LBBB was documented at presentation in 9% of TTC patients. At long-term follow-up, TTC patients with LBBB showed increased unadjusted mortality. However, when adjusted for age, baseline characteristics, and concomitant diseases, LBBB did not appear to be an independent predictor of poor outcome in patients with TTC.