Showing papers in "Texas Heart Institute Journal in 2007"

Systemic infections cause exaggerated local inflammation in atherosclerotic coronary arteries: clues to the triggering effect of acute infections on acute coronary syndromes.

Abstract: Systemic infections can trigger heart attacks We conducted an autopsy study to investigate the pathologic effect of systemic infections on coronary artery inflammation We studied 14 atherosclerotic patients diagnosed with an acute systemic infection Our control group (n=13) had atherosclerosis without infection The groups were similar in luminal stenosis and age Coronary artery sections were stained with HE P=0047) The macrophage density, similar in the control group's adventitia and plaque, was significantly greater in the infected group's adventitia than in the plaque The adventitia and periadventitial fat of the infected group had more T cells than did samples from the control group (484 +/- 450 vs 141 +/- 63 per mm(2); P=0002) The groups exhibited similar plaque T-cell density The infected patients' plaques, but not the adventitia and periadventitial fat, had more dendritic cells than did the controls' (32 +/- 25 vs 03 +/- 05 per mm(2); P=0022) To our knowledge, this is the 1st report to establish a connection between acute systemic infections and significant increases in inflammatory cells in the atherosclerotic coronary arteries of human beings This offers a new therapeutic target for preventing heart attacks in high-risk patients

The Discovery of Aspirin's Antithrombotic Effects

Abstract: Aspirin has long been established as a useful analgesic and antipyretic. Even in ancient times, salicylate-containing plants such as the willow were commonly used to relieve pain and fever. In the 20th century, scientists discovered many details of aspirin's anti-inflammatory and analgesic properties, including its molecular mechanism of action. In addition, the latter half of the century brought reports that daily, low doses of aspirin could prevent myocardial infarction and stroke. This finding was first reported by Lawrence Craven, a suburban general practitioner in Glendale, California. Unfortunately, Craven's work went largely unnoticed, and decades passed before his observations were verified by clinical trial. We present Craven's story, which demonstrates the value of a single physician's commitment to lifelong learning. In addition, we summarize the work of the physicians and scientists who discovered the molecular mechanisms by which aspirin exerts its antiplatelet effects. Collectively, these discoveries exemplify the complementary roles of basic science and clinical observation in advancing medicine.

A history of streptokinase use in acute myocardial infarction.

Abstract: A serendipitous discovery by William Smith Tillett in 1933, followed by many years of work with his student Sol Sherry, laid a sound foundation for the use of streptokinase as a thrombolytic agent in the treatment of acute myocardial infarction. The drug found initial clinical application in combating fibrinous pleural exudates, hemothorax, and tuberculous meningitis. In 1958, Sherry and others started using streptokinase in patients with acute myocardial infarction and changed the focus of treatment from palliation to "cure." Initial trials that used streptokinase infusion produced conflicting results. An innovative approach of intracoronary streptokinase infusion was initiated by Rentrop and colleagues in 1979. Subsequently, larger trials of intracoronary infusion achieved reperfusion rates ranging from 70% to 90%. The need for a meticulously planned and systematically executed randomized multicenter trial was fulfilled by the Gruppo Italiano per la Sperimentazione della Streptochinasi nell'Infarto Miocardico (GISSI) trial in 1986, which not only validated streptokinase as an effective therapeutic method but also established a fixed protocol for its use in acute myocardial infarction. Currently, despite the wide use of tissue plasminogen activator in developed nations, streptokinase remains essential to the management of acute myocardial infarction in developing nations.

Oral Ascorbic Acid in Combination with Beta-Blockers Is More Effective than Beta-Blockers Alone in the Prevention of Atrial Fibrillation after Coronary Artery Bypass Grafting

Abstract: Because adrenergic beta antagonists are not sufficient to prevent atrial fibrillation after coronary artery bypass grafting, this prospective, randomized trial was designed to evaluate the effects of ascorbic acid as an adjunct to β-blockers. Fifty patients formed our ascorbic acid group, and another 50 patients formed our control group. All patients were older than 50 years, were scheduled to undergo coronary artery bypass grafting, and had been treated with β-blockers for at least 1 week before surgery. The mean age of the population was 60.19±7.14 years; 67% of the patients were men. Patients in the ascorbic acid group received 2 g of ascorbic acid on the night before the surgery and 1 g twice daily for 5 days after surgery. Patients in the control group received no ascorbic acid. Patients in both groups continued to receive β-blockers after surgery. Telemetry monitoring was performed in the intensive care unit, and Holter monitoring was performed for 4 days thereafter. The incidence of postoperative atrial fibrillation was 4% in the ascorbic acid group and 26% in the control group (odds ratio, 0.119; 95% confidence interval, 0.025–0.558, P = 0.002). We conclude that ascorbic acid is effective, in addition to being well-tolerated and relatively safe. Therefore, it can be prescribed as an adjunct to β-blockers for the prophylaxis of post-bypass atrial fibrillation.

In vivo evaluation of the HeartWare centrifugal ventricular assist device.

Abstract: In this study, long-term (90-day) hemocompatibility and end-organ effects of a centrifugal left ventricular assist device (the Heartware HVAD™) were evaluated in 6 healthy sheep. The device was implanted into the left ventricular apex on beating hearts. The outflow graft of each device was anastomosed to the descending aorta. None of the sheep received anticoagulation or antiaggregation medication during the study. Hematologic and biochemical tests of liver and kidney function were performed pre-operatively (baseline) and throughout the study. Data associated with pump function were collected continuously until 90 ± 1 days of support, at which time the sheep were humanely killed, and the end-organs were examined macroscopically and histopathologically. Hematologic and biochemical test results were within normal limits during the study period. There were no significant complications. Postmortem examination of the explanted organs revealed no evidence of ischemia or infarction, except in 2 sheep, in which small foci of infarction were detected in each of their left kidneys. There was no significant device failure. In all sheep, the pump's inflow and outflow conduits were free of thrombus. During the 90-day study, the HeartWare HVAD showed exceptional hemocompatibility and reliability, both of which are crucial to the clinical success of any implantable left ventricular assist device.

Prognostic value of 6-minute walk test in stable outpatients with heart failure.

Abstract: The study was designed to evaluate the prognostic value of the 6-minute walk test in stable outpatients with heart failure. We prospectively studied 43 patients (6 women and 37 men) who had chronic heart failure secondary to ischemic heart disease or idiopathic cardiomyopathy. All patients had left ventricular systolic dysfunction (ejection fraction, ≤0.40), and they were in stable New York Heart Association functional class II or III heart failure. All patients were evaluated by M-mode and 2-dimensional echocardiography. At the outset, walking distances of all the patients were evaluated by the 6-minute walk test. The patients were divided into 2 groups: Group I, patients with a 6-minute walk test distance of ≤300 m; and Group II, patients with a 6-minute walk test distance of >300 m. The patients were then monitored for a period of 2 years in regard to cardiac death. The mortality rate was significantly higher in patients with a 6-minute walk test distance of ≤300 m than in patients with a 6-minute walk test distance of >300 m (79% vs 7%; P <0.001). The death risk was found to be significantly higher in patients with a distance of ≤300 m (P=0.005). The death risk was also higher in patients whose left ventricular ejection fraction was ≤0.30 (P=0.02). We conclude that a 6-minute walk test distance of ≤300 m is a simple and useful prognostic marker of subsequent cardiac death in patients with mild-to-moderate heart failure. (Tex Heart Inst J 2007;34:166–9)

Initial clinical experience with the HeartMate II axial-flow left ventricular assist device.

Abstract: We have seen excellent results with use of the HeartMate II. Functional status and quality of life have greatly improved in patients who survived the perioperative period.

Takotsubo cardiomyopathy, or broken-heart syndrome.

Abstract: Takotsubo cardiomyopathy mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. In Japanese, "takotsubo" means "fishing pot for trapping octopus," and the left ventricle of a patient diagnosed with this condition resembles that shape. Takotsubo cardiomyopathy, which is transient and typically precipitated by acute emotional stress, is also known as "stress cardiomyopathy" or "broken-heart syndrome."Herein, we describe the clinical angiographic characteristics of 4 patients who exhibited this syndrome, and we review the existing literature and propose reasons to conduct prospective studies.

Acute massive pulmonary embolism with cardiopulmonary resuscitation: management and results.

Abstract: Patients who experience hemodynamic collapse after acute massive pulmonary embolism have a poor prognosis. Herein, we report our results with 8 patients and discuss a surgical strategy that can improve perioperative survival. From August 1994 through May 2005, 8 consecutive patients (6 women, 2 men; age range, 27-68 yr) were urgently referred to our unit after experiencing hemodynamic collapse. All required cardiopulmonary resuscitation. Seven patients underwent pulmonary embolectomy. One patient was successfully treated with thrombolytic therapy alone under continuous monitoring by the surgical team. There were 2 intraoperative deaths (30-day mortality rate, 28.5%). One survivor required a right ventricular assist device. Follow-up of the patients ranged from 8 months to 8 years. One patient died 8 months after the pulmonary embolectomy from long-term complications of cerebral damage that had occurred during preoperative resuscitation. We conclude that prompt surgical management improves the early survival rates of patients who require cardiopulmonary resuscitation subsequent to massive pulmonary embolism.

Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience.

Abstract: Herein, we present a retrospective analysis of our experience with acquired pseudoaneurysms of the left ventricle over a 20-year period.From February 1985 through September 2004, 14 patients underwent operation for left ventricular pseudoaneurysm in our clinic. All pseudoaneurysms (12 chronic, 2 acute) were caused by myocardial infarction. The mean interval between myocardial infarction and diagnosis of pseudoaneurysm was 7 months (range, 1-11 mo). The pseudoaneurysm was located in the inferior or posterolateral wall in 11 of 14 patients (78.6%). In all patients, the pseudoaneurysm was resected and the ventricular wall defect was closed with direct suture (6 patients) or a patch (8 patients). Most patients had 3-vessel coronary artery disease. Coronary artery bypass grafting was performed in all patients. Five patients died (postoperative mortality rate, 35.7%) after repair of a pseudoaneurysm (post-infarction, 2 patients; chronic, 3 patients). Two patients died during follow-up (median, 42 mo), due to cancer in 1 patient and sudden death in the other. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. Surgical repair is warranted particularly in cases of large or expanding pseudoaneurysms because of the propensity for fatal rupture.

Iliac vein stenting for chronic venous insufficiency.

Abstract: Chronic venous insufficiency has devastating sequelae in terms of patients' lifestyles and negative economic impact on society. Traditional surgical procedures have yielded variable patency results, and follow-up has not always been reported. This review summarizes the current applications, patency rates, stent selection, and complications of balloon angioplasty and stenting in the treatment of chronic venous outflow obstruction in the lower extremity. We conclude that endovenous stenting is the current method of choice in the treatment of chronic venous obstruction.

Mesenteric Oxygen Desaturation in an Infant with Congenital Heart Disease and Necrotizing Enterocolitis

Abstract: Congenital heart disease is a risk factor for the development of necrotizing enterocolitis, although the exact mechanism of development remains unclear. Herein, we report the case of an infant with pulmonary atresia, an intact ventricular septum, and multiple aortopulmonary collateral vessels. At 4 weeks of age, the infant developed necrotizing enterocolitis in association with significant mesenteric oxygen desaturation, as measured by means of near-infrared spectroscopy. With bowel rest and antibiotic therapy, the patient's mesenteric oxygen saturation and clinical status improved. This case highlights the importance of impaired mesenteric oxygen delivery consequential to congenital heart disease as a possible risk factor for necrotizing enterocolitis, and the use of near-infrared spectroscopy to measure tissue perfusion noninvasively in high-risk patients. To our knowledge, this is the 1st report of mesenteric oxyhemoglobin desaturation in association with necrotizing enterocolitis in a patient who also had congenital heart disease.

The Origin of Echocardiography: A Tribute to Inge Edler

Abstract: The original description of M-mode echocardiography in 1953, by Inge Edler (1911–2001) and his physicist friend Hellmuth Hertz, marked the beginning of a new diagnostic noninvasive technique. Edler used this technique primarily for the preoperative study of mitral stenosis and diagnosis of mitral regurgitation. His work was carried forward by cardiologists all over the world, who developed Doppler, 2-dimensional, contrast, and transesophageal echocardiography. These are now standard in cardiologic examinations. Edler also influenced neurologists and obstetricians at Lund University (Sweden) to use ultrasound in their fields. For his landmark discovery, Edler is recognized as the “Father of Echocardiography.”

Lambl's excrescences: review and recommendations.

Abstract: Lambl's excrescences are filiform fronds that occur at sites of valve closure. They originate as small thrombi on endocardial surfaces (where the valve margins contact) and have the potential to embolize to distant organs. We describe the case of a 61-year-old woman who presented with repeated episodes of stroke. She was found to have Lambl's excrescences on all 3 leaflets of the aortic valve. After all other possible causes of stroke were ruled out, she underwent successful open heart surgery for debridement of these excrescences. The histopathologic diagnosis was consistent with Lambl's excrescences. Our patient did not have any cerebrovascular embolic event after surgery. Because of its high sensitivity to detect excrescences, transesophageal echocardiography should be included in the diagnostic assessment of all patients who have experienced strokes. Asymptomatic patients who are found to have evidence of Lambl's excrescences should be monitored closely. If there is evidence of 1 cerebrovascular accident in a patient with Lambl's excrescences, anticoagulation is advised. Any suggestion of a 2nd such episode should lead to operative removal of Lambl's excrescences.

Open-heart surgery in Nigeria: indications and challenges.

Abstract: From the early 1940s through the 1950s, it was a popular belief throughout the world that cardiac diseases were rare among Nigerians. However, the establishment of the cardiac registry in 1964 in Ibadan revealed all types of cardiac diseases, including those requiring surgical intervention.1 Virtually all who were affected died without help, except for those who traveled to Europe or America for treatment. Now, the situation is different because of new cardiac centers in Nigeria. At the University of Nigeria Teaching Hospital (UNTH) in Enugu, the first open-heart surgery in Nigeria was performed on 1 February 1974.2 The team of surgeons included M. Yacoub, F.A. Udekwu, D.C. Nwafor, C.H. Anyanwu, and others. By the year 2000, a total of 102 such operations had been carried out at the center by different Nigerian teams, with Professor Martin Aghaji's team being in the forefront (Fig. 1). The patients ranged in age from 2.5 years to 63 years. Forty-six (45%) patients were aged between 11 and 20 years (Fig. 2). Fig. 1 Fluctuations, from 1974 through 2000, in numbers of open-heart-surgery patients treated throughout Nigeria. Fig. 2 Histogram showing the number of patients per age-group during the 1974–2000 period. Cases of mitral valve disease, at 40 (39.2%) in number, topped the list of the pathological processes. These included mitral stenosis, mitral regurgitation, and combined lesions. The high incidence of mitral valve disease has been attributed to the aftereffects of rheumatic heart disease in the region.3 Mitral valve disease was followed in frequency of observation by 16 (15.7%) cases of ventricular septal defect (VSD), 13 of tetralogy of Fallot (12.7%), and 12 of atrial septal defect (11.8%). There were 7 cases of ascending aorta–aortic arch aneurysm. Other lesions included ventricular aneurysm and total anomalous pulmonary venous connection. These 102 patients are of course far fewer than the World Health Organization's estimated figure for Nigeria, with its population of 126 million. Our center at Enugu was for a long while the only center in Nigeria that was doing open-heart surgery. The patients treated were the young, those who could afford the fees, and those whose cases could be handled by our center. The average age of our patients was 20 years. Many were in their youth, because experience has shown that the outcome of open-heart surgery is better among young people. Nigeria lacks facilities to combat the comorbid conditions that are prevalent among elderly patients. By 2003, when Dr. William Novick's International Children's Heart Foundation paid a working visit to Enugu, the Kanu Heart Foundation, which had invited the team, had a registry of 2,555 heart disease patients who needed open-heart surgery. These were drawn from the KHF registry, UNTH, and other hospitals. Of the 72 patients evaluated during that visit, more than 50 required open-heart surgery, but only 9 had the surgery. What is needed is political will on the part of the policymakers to act in providing adequate human and material resources in the Enugu center and in the 2 new centers in Lagos and Ibadan. All of these centers are government owned. It is of course more cost-effective to treat Nigerians in these centers than anywhere else in the world. In Nigeria, the challenges facing the cardiac surgery team are many. A look at Figure 1 shows no definite pattern in the number of patients per year. Ups and downs in patient population have characterized activity at the Enugu center, and the same is true for the other centers. Among the reasons for this state of affairs is the unavailability of high technology. All the equipment is imported from other countries, as are virtually all of the required drugs and prosthetic devices. These things must be paid for in United States dollars; and because of the current severe devaluation of the Nigerian naira, many of these items are lacking. Therefore, the cardiac team has to improvise. As a result of the heavy financial outlay for surgical treatment, cardiac patients must pay more, on average, than do other patients in the hospital. Many of these patients and their relatives cannot afford the bill. Moreover, there is no health-insurance scheme for this kind of treatment. (There was no health insurance at all until 2004, and even now cardiac surgery is not covered.) We have a situation wherein the government of the day has succeeded in providing some infrastructure, but most patients cannot benefit from what is available. Because all 3 centers that perform open-heart surgery in Nigeria are government owned, there is some small subsidy for patients' bills. When compared with the costs of treatment abroad, the cost of treating patients at home is still far lower.4 A total hospital bill for open-heart surgery without a prosthesis typically costs $4,800; with a prosthesis, it costs $5,600. An overnight stay in the intensive care unit is about $85, while a gram of the Rocephin antibiotic agent for injection is $20. Payment sources generally are: household, 62.5%; employer, 20.5%; government, 9%; and donors, 8%. The minimum wage in Nigeria is between $44 and $62 per month. The per capita income estimate in 2004 was $1,050. Nigeria's gross domestic product for that year was $64.1 billion, but with the estimated 126 million people, this amounts to $493 per capita. Poor medical and surgical training and skills leave room for trial and error. Every member of the team is expected to be proficient, but there is a need for further training, workshops, seminars, recertification, and continuing education. Unfortunately, the “brain-drain syndrome” has adversely affected the growth of cardiac surgery in Nigeria. The surgical management of heart disease is labor intensive, but there is little incentive to stay in Nigeria. Something urgent must be done to reverse the situation. This is where a leader with vision is needed. Political instability in the country and frequent widespread violence combine to limit the number of foreign agencies that participate in the surgical management of heart disease in Nigeria. Some of these charities have personnel and equipment. Some foreign physicians want experience in treating types of heart disease that are no longer common in their countries. However, even charitable organizations cannot take their safety for granted. Furthermore, political decisions that affect the treatment of heart disease vary with each political leader, and these leaders change very often. Their successors do not maintain continuity. Some emphasize primary health care to the detriment of the treatment of heart disease. It is well known that our hospital and other health institutions have been experiencing inter-professional conflicts. It was a topic at the health summit in Abuja in 1995.5 These conflicts rob patients of the united attention that is necessary to achieve greater levels of success. There is a need to improve human relationships among staff, because the patient should be our rallying point. Another problem is that fraudulent contractors and their collaborators often supply us with outdated and nonfunctional equipment. The end user is seldom involved in the purchase of such items. Moreover, much of the equipment is now computer-based, and computer illiteracy and poor handling lead to frequent breakdowns. If we could use the information technology that is now available, retrieval of information would be easier, and planning and management would become more comfortable. Much more basic challenges are the lack of regular water and electric power supply, nonpayment of salary when due, stagnation of staff services, and lack of knowledge about modern information technology on the part of personnel who carry out patient services. Apart from open-heart surgery, other cardiothoracic procedures are carried out at UNTH. In a retrospective analysis of inpatient admission records from 2000 through 2004, all cardiothoracic cases (704) were documented. Chest-wall disorders constituted most of the cases (28.68%), and chest trauma from traffic accidents accounted for the majority of these (Table I). Pyothorax that required decortication was high on the list of pleural collections. Third were esophageal disorders such as corrosive stricture, achalasia, and cancer of the esophagus. TABLE I. Distribution of Cardiothoracic Lesions Treated 2000 through 2004 Despite all of this, we believe that Nigeria has what it takes to attain self-sufficiency in the treatment of heart diseases that require open-heart surgery. What is needed is the normalization of these irregularities and the good management of resources. The recently introduced health-insurance scheme may help.

Inferior vena cava filters for recurrent thrombosis: current evidence.

Abstract: Inferior vena cava filters are often used as alternatives to anticoagulant therapy for the prevention of pulmonary embolism. Many of the clinical data that support the use of these devices stem from relatively limited retrospective studies. The dual purpose of this review is to examine the incidence of thrombotic complications associated with inferior vena cava filters and to discuss the role of anticoagulant therapy concurrent with filter placement. Device-associated morbidity and overall efficacy can be considered only in the context of rates of vena cava thrombosis, insertion-site thrombosis, recurrent deep venous thrombosis, and recurrent pulmonary embolism.

Intimal Sarcoma of the Pulmonary Artery with Retrograde Extension into the Pulmonic Valve and Right Ventricle

Abstract: We describe the case of a 42-year-old man who presented with dyspnea on exertion and a history of anticoagulation therapy for what was thought to be pulmonary arterial thromboembolism. He underwent surgery for obstruction of the right ventricular outflow tract. This is a very rare case of an intimal sarcoma of the pulmonary artery, which we confirmed by pathologic studies.

Right ventricular thrombus with Behçet's syndrome: successful treatment with warfarin and immunosuppressive agents.

Abstract: Behcet's syndrome is a chronic multisystem disease that presents with recurrent oral and genital ulceration and recurrent uveitis. Cardiac involvement is an extremely rare manifestation of this disorder. A 33-year-old man with Behcet's syndrome was admitted to our department with a history of cough, fever, chest pain, hemoptysis, and weight loss. Transthoracic and transesophageal echocardiography revealed a right ventricular thrombus. After 1 month of treatment with warfarin, cyclophosphamide, and corticosteroid, the intracardiac thrombus resolved.

A synopsis of research in cardiac apoptosis and its application to congestive heart failure.

Abstract: Cardiac apoptosis diminishes the contractile mass, which leads to heart failure. Apoptosis of cardiac non-myocytes also contributes to maladaptive remodeling and the transition to decompensated congestive heart failure. New antiapoptotic interventions and medications will be available within the next decade. The aim of this study is to provide a critical synopsis of research projects on cardiocyte apoptosis that have implications for current and future practice and to identify methods to prevent or attenuate apoptosis in patients who have poor ventricular function. A retrospective literature review reveals a great many important publications. However, very few investigators discuss the clinical ramifications of cardiocyte apoptosis, nor do they address the clinician who sees poor ventricular contractility daily. Most studies are still investigational and involve antiapoptotic agents such as broad-spectrum caspase inhibitors, antioxidants, calcium channel blockers, insulin-like growth-factor 1, and poly(adenosine diphosphate ribose) synthetase inhibitors. Some options have already been incorporated into the clinical practices of cardiologists and cardiac surgeons: repairing or replacing diseased or damaged valves before ventricular function deteriorates; reducing afterload with medication or intra-aortic balloon pulsation in patients who display acute increases in afterload; decreasing catecholamine-induced cardiotoxicity in hemodynamically compromised patients, by using β-blockers and phosphodiesterase inhibitors; and inserting intra-aortic balloon pumps or ventricular assist devices early in cases of failing myocardium. Coronary revascularization early in myocardial infarction is effective antiapoptotic therapy. Other therapeutic targets are cardiopulmonary bypass and aortic cross-clamping, both of which require reductions in associated myocardial apoptosis.

Cardiac tamponade revisited: a postmortem look at a cautionary case.

Abstract: Cardiac tamponade is a life-threatening clinical syndrome that requires timely diagnosis. Herein, we present an instructive case of a patient who had cardiac tamponade. The condition went undiagnosed and resulted in the patient's death because almost all of the pathognomonic clinical findings of tamponade were unrecognized or not manifest. To better prepare health care professionals for similar challenges, we discuss the symptoms and clinical signs typical of cardiac tamponade, review the medical literature, and highlight current investigative methods that enable quick, efficient diagnosis and treatment.

Systemic and myocardial inflammation : in traditional and off-pump cardiac surgery

Abstract: In this study, we attempted to determine the role of off-pump coronary artery bypass grafting (CABG) in the myocardial and systemic inflammatory responses. Twenty patients who underwent elective CABG were enrolled in this study. Ten patients underwent on-pump CABG, and 10 patients underwent off-pump CABG. There were no differences between patients in preoperative clinical variables. We took systemic venous blood samples for the measurement of tumor necrosis factor-alpha, the MB isoenzyme of creatine kinase (CK-MB), and cardiac troponin I, and we took myocardial biopsies from the interventricular septum for chemiluminescence assay of reactive oxygen species (hydroxyl, hydrogen peroxide, hypochlorite, and superoxide). There was no significant difference in the myocardial tissue release of hydrogen peroxide, hydroxyl, hypochlorite, and superoxide between the 2 groups (P > 0.05). The systemic tumor necrosis factor-alpha levels in the off-pump group were significantly lower than in the on-pump group (P 0.05). We conclude that off-pump CABG appears to reduce systemic inflammation, without reducing myocardial oxidative stress and inflammation.

Endovascular repair of paraanastomotic aneurysms after aortic reconstruction.

Abstract: We designed this retrospective study to evaluate the effectiveness of percutaneous approaches for repair of paraanastomotic aneurysms that develop after surgical aortic reconstruction. The catheterization records of patients who had undergone percutaneous repair of para-anastomotic aneurysms from January 2001 through December 2005 were reviewed, and data regarding preoperative aneurysm size, risk factors, intraoperative techniques, morbidity, and death were recorded. Eight patients had undergone exclusion of a total of 10 paraanastomotic aneurysms. The average age of the prosthetic graft at diagnosis was 11.7 years. Four of the patients were symptomatic; none of these had a ruptured aneurysm. All patients received commercially available devices. Technical success was achieved in all patients. Conscious sedation alone was administered to 7 patients. There were no in-hospital deaths, and morbidity was minimal. We conclude that endovascular exclusion of paraanastomotic aneurysms after aortic reconstruction is a viable alternative to open surgical repair and greatly reduces the risk of morbidity and death.

The “1st Septal Unit” in Hypertrophic Obstructive Cardiomyopathy: A Newly Recognized Anatomo-Functional Entity, Identified during Recent Alcohol Septal Ablation Experience

Abstract: In hypertrophic obstructive cardiomyopathy, selective and asymmetric hypertrophy results in a stenotic subaortic channel, which is further narrowed by a Venturi effect (suctioning of the anterior leaflet, manifested by systolic anterior motion of the mitral valve). Better understanding of these essential pathophysiologic mechanisms has led to the definition of a new anatomo-functional entity, the 1st septal unit, which consists of the basal interventricular septal hypertrophy and its related septal arterial branches. As an alternative to surgical myomectomy, alcohol septal ablation is an effective method of reducing subaortic stenosis and improving mitral valve function. After alcohol ablation, global negative remodeling of the hypertrophied left ventricle eventually ensues. This review presents specific anatomic and functional features of a newly identified pathophysiologic entity (the 1st septal unit) in relation to the clinical manifestations and natural history of hypertrophic obstructive cardiomyopathy. This relationship is also relevant during the performance of alcohol septal ablation interventions: related operative suggestions are provided for optimizing subaortic stenosis relief during septal ablation and for preventing complications.

Effects of carvedilol on plasma levels of pro-inflammatory cytokines in patients with ischemic and nonischemic dilated cardiomyopathy.

Abstract: We prospectively investigated the effects of adding carvedilol to the standard treatment of ischemic and nonischemic dilated cardiomyopathy (DCM), by measuring the plasma levels of pro-inflammatory cytokines. Sixty patients with DCM (35 ischemic and 25 nonischemic) were divided into 2 subgroups: patients on standard therapy alone (digoxin, angiotensin-converting enzyme inhibitors, and diuretics) and patients on standard therapy plus carvedilol. Study participants' serum levels of tumor necrosis factor-α (TNF-α), interleukin-2 (IL-2), and interleukin-6 (IL-6) were measured at the beginning and again at the end of the study. Left ventricular ejection fraction and left ventricular diastolic function were evaluated by means of radionuclide ventriculography. In ischemic patients on carvedilol, levels of IL-6 and TNF-α dropped significantly (P= 0.028 and P=0.034, respectively). In ischemic patients on standard treatment, plasma IL-2 levels were elevated after treatment (P=0.047). No significant differences occurred in IL-6 levels, while TNF-α levels were elevated (P=0.008). In nonischemic patients on carvedilol, IL-6 and TNF-α levels dropped significantly (P=0.018 and P=0.004, respectively). The left ventricular ejection fraction increased significantly (P=0.006). In nonischemic patients on standard treatment, no significant change occurred in any value. Carvedilol suppressed the plasma levels of TNF-α and IL-6 in both ischemic and nonischemic patients. The carvedilol effect was more pronounced in patients with nonischemic dilated cardiomyopathy than in those with ischemic disease.

Transient Cortical Blindness after Cardiac Catheterization with Iobitridol

Abstract: The occurrence rate of transient cortical blindness after contrast media exposure has been reported to be as high as 1% to 4% after cerebral or vertebral angiography, but such blindness has been described in only a few cases of coronary angiography with modern, non-ionic, low-osmolality radio-contrast agents. In this study, we present a case of abrupt cortical blindness after exposure to contrast media during diagnostic coronary angiography; to our knowledge, this is the 1st report in the medical literature that describes transient cortical blindness after iobitridol use.

Giant, dumbbell-shaped pericardial cyst.

Abstract: A 68-year-old woman presented with chest pain and dyspnea. The results of physical examination and electrocardiography were within normal limits, but a posteroanterior chest radiograph revealed a mass in the upper mediastinum. Subsequent computed tomography (CT) and magnetic resonance imaging (MRI) revealed a dumbbell-shaped cyst surrounding the heart (Figs. 1 and ​and2).2). The cyst occupied a large space in the mediastinum and involved both sides of the chest. The portion of the cyst in the right paracardiac region was 9 × 12 × 13 cm; the portion in the left paracardiac region was 3 × 10 × 13 cm. Those 2 components of the cyst were joined to each other in front of the ascending aorta at the aorticopulmonary level. The cyst, thought to be pericardial, was removed by open thoracotomy. Histopathologic examination revealed that the cyst was lined with a single layer of cuboidal epithelium (Fig. 3) and was filled with clear fluid; accordingly, the preoperative diagnosis was confirmed. Fig. 3 Photomicrograph of a section of the cyst that is lined with single-layered cuboidal epithelium (H&E, orig. ×200). Fig. 2 Coronal magnetic resonance imaging scans show A) a hyperintense lesion on a fat-saturated T2*-weighted image, and B) a hypo-intense, non-enhancing lesion on a contrast-enhanced T1-weighted image, both consistent with a pericardial cyst. ... Fig. 1 Axial contrast-enhanced computed tomographic scans of the chest (mediastinal window) at the level of the left ventricle (A) and the aorticopulmonary window (B) show a non-enhanced, low-attenuated, well-circumscribed, dumbbell-shaped mass adjacent ...

Pheochromocytoma underlying hypertension, stroke, and dilated cardiomyopathy.

Abstract: We report the case of a 65-year-old man with a 6-year history of hypertension who presented with dilated cardiomyopathy, a transient cerebrovascular event, paroxysmal sweating, and intractable hypertension. Coronary angiography revealed no abnormality, but diagnostic testing was pursued because of the severe sweating and hypertension. Two-dimensional echocardiography showed 4-chamber dilatation with decreased left ventricular contractility. Further investigation, including a computed tomographic scan of the abdomen, led to a di-agnosis of pheochromocytoma. Surgical resection of a left adrenal pheochromocytoma quickly resolved the patient's hypertension and resulted in substantially improved cardiac function after 4 months. Although pheochromocytoma has rarely been reported in the presence of both dilated cardiomyopathy and cerebrovascular events, it should be included in the differential diagnosis when patients present with dilated cardiomyopathy and a cerebrovascular event that have no obvious cause.

Aspergillus endocarditis of the mitral valve in a lung-transplant patient.

Abstract: A 57-year-old man underwent bilateral lung transplantation at our hospital. On histopathology, aspergillomas were identified in the upper lobes of the explanted lungs. After being treated and discharged from the hospital, he returned 4 months later with ischemic chest pain, which was due to a myocardial infarction complicated by cardiogenic shock. He also had a large vegetation on the anterior mitral leaflet. Herein, we describe the patient's symptoms, complications, treatment, and recovery. To the best of our knowledge, ours is only the 2nd report of a patient who developed Aspergillus endocarditis after lung transplantation and the 1st such patient to have undergone successful mitral valve replacement.

Cor triatriatum dexter.

Abstract: A 68-year-old woman presented with cellulitis of the left leg. She had a history of hypertension, obesity, and chronic lymphedema of the lower left leg. On admission, roentgenography of the chest showed possible cardiomegaly, but other cardiovascular findings were normal. An initial transthoracic echocardiogram was thought to show a right atrial mass that measured 1.2 × 1.6 cm (Fig. 1). The suspected mass appeared to arise from the interatrial septum. Transesophageal echocardiography (Fig. 2) showed a normal right atrium. An unusually prominent eustachian valve arose normally from the ostium of the inferior vena cava and was attached to the interatrial septum just below the level of the fossa ovalis (Figs. 2 and ​and3).3). The valve measured 1.2 × 2.6 cm in its greatest thickness and partitioned the right atrium into roughly 2 chambers (Figs. 4 and ​and5).5). Intravenous saline contrast injection (Fig. 5) showed partitioning of the right atrium into 2 chambers by this membrane. Inferior vena caval flow was not obstructed. These findings were consis-tent with cor triatriatum dexter. Fig. 1 Transthoracic echocardiogram in 4-chamber view shows the right atrial mass (arrowhead). Fig. 2 Transesophageal echocardiogram in 4-chamber view shows a prominent eustachian valve (arrowhead) attached to the interatrial septum just below the level of the fossa ovalis. Fig. 3 Transesophageal echocardiogram shows the eustachian valve viewed from the superior vena cava. Fig. 4 Transesophageal echocardiogram in the color-flow Doppler short-axis view shows flow across the membrane (arrowhead). Fig. 5 Transesophageal echocardiographic bubble study shows partitioning of the right atrium into 2 chambers.

Endovascular stenting for primary aortobronchial fistula in association with massive hemoptysis.

Abstract: Aortobronchial fistula is a potentially lethal complication secondary to the repair of a descending thoracic aneurysm or the placement of a prosthetic graft. Few cases have been reported. Very rarely, primary aortobronchial fistula occurs in a patient who has no history of cardiac surgical intervention. Herein, we present the cases of 2 patients whose massive, life-threatening bleeding from primary aortobronchial fistulae was successfully treated with endovascular stenting. Endovascular stenting is an emerging treatment method that can be used in this emergency setting with promising results and without early graft-related sequelae.