The purpose of this paper is to report a congenital subclavian artery to subclavian vein fistula in a three weeks old male infant who presented with congestive heart failure and pulmonary hypertension. He had been scanned by various imaging modalities including echocardiography, cardiac computed tomography, diagnostic cardiac catheterization, cardiac magnetic resonance angiocardiography and cranial computed tomoangiography. He had successful surgical ligation after failure of device occlusion trial at age of 9 months.
Pulmonary vein stenosis in adults is historically a rare condition, but is becoming a recognised complication, albeit an uncommon one, of radiofrequency ablation around the pulmonary veins for treatment of atrial fibrillation. It may also be due to infiltrating mediastinal processes such as neoplasm or sarcoidosis. In this case report, a 55-year-old man underwent resection of a mediastinal phaeochromocytoma involving the left atrial wall and the right inferior pulmonary vein. One year later he subsequently presented with increasing dyspnoea and atypical chest pain. Transthoracic echocardiogram showed severe pulmonary hypertension, right ventricular dilatation and dysfunction. Transesophageal echocardiogram demonstrated severe bilateral pulmonary vein stenosis with peak/mean gradients across the left pulmonary veins of about 25/20mmHg. The diagnosis was also confirmed on CT pulmonary angiography with 3D reconstruction. Open pulmonary vein stenting was planned but unfortunately the patient died suddenly before the procedure. Pulmonary vein stenosis is an uncommon but serious condition and may present with signs and symptoms indistinguishable from other conditions and may easily be missed. Clinicians should have a high index of suspicion when patients present with unexplained respiratory symptoms, especially in the context of catheter ablation or mediastinal processes such as neoplasm. Transesophageal echocardiography played an indispensible part in the correct diagnosis in our patient.
A 71-year-old Japanese man was admitted to our hospital complaining of chest oppression on exercise, such as cycling uphill, which had continued for 9 years. We diagnosed him as having microvascular spasm according to the results of coronary angiography with an acetylcholine provocation test with a high dose (150mg) of acetylcholine administrated at a time during 20 seconds. Electrocardiographic changes during the spasm provocation test resembled that during exercise tests performed upon admission and 9 years previously. He was treated with a calcium channel blocker and partial symptom relief was obtained.
In Fontan patients, reduced exercise capacity due to diminished cardiac output is a common finding with important prognostic implications. Beneficial effects have been shown for sildenafil treatment and regular exercise, but data comparing both strategies is scarce. We report on a female patient with Fontan circulation who underwent repeated cardiopulmonary exercise tests with either placebo or a single dose of 50mg sildenafil before and after 6months of supervised aerobic and resistance exercise. At baseline, O2peak was 29.1ml/min/kg, and a marked increase to 32.8ml/min/kg was observed after administration of sildenafil. After the training period, O2peak was 34.5ml/kg/min in the placebo test, and no further increase by sildenafil was possible (33.7ml/kg/min). Similar results were observed for exercise capacity at the ventilatory anaerobic threshold. In summary, this Fontan patient showed that regular exercise might use up and probably exceed the acute sildenafil effects on exercise capacity. Exercise should be considered as a primary treatment strategy within secondary prevention and rehabilitation after the Fontan procedure.
Extracorporeal membrane oxygenation (ECMO) for septic shock has been reported occasionally and it has been shown to have reasonable outcomes in pediatrics cases. However, the adult ECMO for septic shock is not as clearly elucidated. Here we present a case of adult ECMO for septic shock secondary to MRSA, complicated by multi-organ abscesses. This case illustrates that MRSA sepsis is a major contraindication for the use of ECMO.
Objective: High load of regularly vigorous exercise leads to multiple physiological adaptations. The major cardiovascular effects are hypertrophy and dilation, predominantly of the left ventricle, and bradycardia. However, there are no reports on an athlete’s heart in a systemic right ventricle.
Subject: We report on a 23 year old male endurance athlete (177cm, 69kg) with a systemic subaortic right ventricle after atrial redirection (Senning procedure) for simple transposition of the great arteries in infancy. Albeit medical doctors had imposed activity restriction to him, he has lead an active lifestyle from early childhood on, intensifying his sport activities over the years especially in cycling and running to a training volume of about 10 hours per week in winter and about 15 hours per week in summer. In 2009 he performed 1:50h on the half marathon distance. In 2013 he finished his first Marathon in 4:34h.
Results: Cardiopulmonary exercise testing revealed a maximum oxygen uptake of 52.3ml/min/kg and a peak work load of 353 Watt, corresponding to 5.1Watt per kilogram body mass. Cardiovascular Magnetic Resonance showed a cardiac index of 2.9ml/min/m², a tricuspid regurgitation fraction of 4%, and a systemic right ventricle end-diastolic volume of 109ml/m² with an ejection fraction of 53%.
Conclusions: With regular exercise training a systemic right ventricle can become very efficient comparable to healthy amateur athletes.
Primary cardiac tumors are rare with myxoma being the most common benign cardiac tumor. They are usually sporadic, affecting left atrium and frequently occur in women. They are known to cause valvular obstruction, thromboembolism and arrhythmias. We present a case of right atrial myxoma complicated by pulmonary embolism. The atrial myxoma was diagnosed on autopsy.
Introduction: Infantile Hepatic hemangioendothelioma is characterized by multifocal benign vascular dilatations involving the liver. The clinical course depends on tumor size, localization and complications.
Case Report: 15 days old neonate with stormy postnatal period was referred for intractable congestive cardiac failure. Transthoracic 2D echocardiography showed multiple vegetations on all the four valves, noncompaction of left ventricle with multiple vascular channels in left lobe of liver. Computed tomography angiogram showed 58x29x50 mm markedly enhancing lesion in left lobe of liver suggestive of infantile hepatic hemangioendothelioma. The neonate was treated for bacterial endocarditis. Later 6x6 Amplatzer duct occluder II was parked in hepatic vein, then gel foam and polyvinyl chloride particles were injected into infantile hepatic hemangioendothelioma. Cardiac failure resolved with marked regression of lesion.
Discussion: Infantile hepatic hemangioendothelioma is a rare anomaly causing heart failure in neonate causing death in up to 70% of untreated infants without adequate regression of lesion. Therefore aggressive treatment is warranted. For the first time in the world, we report a case of infantile hepatic hemangioendothelioma in a neonate, with pump failure due to noncompaction of left ventricle and vegetations on all four valves, successfully treated by combination of transcatheter deployment of Amplatzer duct occluder II to occlude the venous end and hand injection of gel foam and polyvinly chloride particles from the aortic end to close the feeder artery.
Conclusion: The combination of closure of hepatic vein by Amplatzer duct occluder II and injection of gel foam and polyvinyl chloride particles is safe and effective in infantile hepatic hemangioendothelioma in neonate with heart failure.
We describe a technique for reanalyzing total chronic long occlusion of the iliac arteries (TASC/D) through the radio-brachial approach.
After having obtained the arterial approach, a 6F 90cm long Shuttle sheath (Cook Group, Bloomington, IN, USA) or a 4F 100cm Fortress sheath (Biotronik AG, Bulack, Switzerland) has been inserted into the left radial or brachial artery reaching the distal aorta, where an injection through the catheter has been made to assess the proximal occlusion cap. A 125 long MPA 4 or 5F catheter has been advanced over a coronary. 014” CTO guide-wire. The coronary guide-wire has been replaced with a Terumo guide-wire leaving the catheter into the first 4-5cm to the occlusion and a subintimal recanalization of the distal portion of the occlusion has been accomplished. Balloon dilation and implantation of long or multiple self-expandable stent have been accomplished to obtain patency of the vessels.
The described technique appeared to be simple and safe allowing for recanalization of long iliac segments independently from the access, femoral or radial/brachial used. Large studies with long follow up are warranted to assess long-term effectiveness.
Aims: Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). History of diabetes mellitus (DM), chronic kidney disease (CKD) and elevated GRACE risk score are all factors defining a higher risk of MACE. We aimed to compare the outcome of patients with early vs selective invasive strategy according to the risk factors at presentation.
Methodology: We enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), 52 (29.2%) had DM, 32 (19.7%)-CKD, defined when MDRD measured glomerular filtration rate (GFR) was <60ml/min/1.73m2 and 28 (15.7%) had GRACE≥140. The study had two arms: an early invasive strategy one (coronary arteriography and percutaneous coronary intervention within 24 hours after admission), and a selective invasive strategy arm (medical stabilization, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). Follow-up was 22.8±14 months.
Results: For the whole group MACE occurred less often and the event free period was longer in the early invasive strategy group compared to selective invasive one (p=0.001). Early invasive strategy in diabetic patients, those with CKD and with GRACE ≥140 was associated with a reduced MACE rate (p=0.008, 0.016 and 0.006, respectively) and longer time to MACE occurrence compared with the selective invasive strategy.
When we evaluated separately non-diabetics, patients with normal renal function and those with GRACE <140 we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. Early invasive strategy, however, showed some advantage over the selective one also in the subgroup analysis-the time to occurrence of MACE was prolonged in patients with lower risk at presentation.
Conclusions: Early invasive strategy in UA/NSTEMI is associated with a reduced MACE rate and longer event-free period compared with selective invasive strategy. This benefit is clearly evident in higher risk subsets (patients with DM, CKD and GRACE ≥140).
Aim: The current study aims to examine the balance between glutathione and glutathione sulfide and how this was disturbed in patients with impaired fasting glucose (IFG) level. The study also included 8-hydroxy-2’-deoxyguanosine to provide a more comprehensive picture of the overall redox state.
Methodology: A cross-sectional analysis of ninety medication free participants without reported history of cardiovascular disease and/or diabetes mellitus was undertaken with data collected from the Diabetes Complications Research Initiative database at Charles Sturt University. Fasting blood glucose, HbA1c and cholesterol as standard markers for diabetes mellitus and associated complications were measured in addition to the emerging biomarkers glutathione (GSH), glutathione disulfide (GSSG), and urinary 8-hydroxy-2’-deoxyguanosine (8OHdG).
Results: The IFG group had a mean blood glucose level above 6.1mmol/L being significantly higher compared to control (P<0.001). Traditional clinical markers were all within the normal range for both groups. However the GSH/GSSG ratio (8.53±5.4 vs 6.62±2.2, P=.04) was significantly lower in the IFG group. GSH and 8OHdG, being markers for oxidative stress, were not significantly different between the two groups.
Conclusion: The free radical related changes in metabolic redox pathways are linked to oxidative stress and related pathologies but may not be associated with disease progression, providing an explanation why conflicting results are presented in the literature concerning any individual biomarkers and risk of diabetes. Our study included individuals with no medication use and mild hyperglycemia (impaired fasting glucose) and indicates a pro-oxidant response to mild-moderate hyperglycemia with a moderate rise in oxidative DNA damage.
Objective: To evaluate the role of angiogenesis in tumor growth by the assessment of mean vessel density and to quantify angiogenesis as an important variable in endometrial cancers.
Material and Methods: 53 cases of endometrial malignancies (epithelial tumors-36 cases and metastatic tumors-17 cases), were analysed for histological types, grades and features like depth of invasion and vascular invasion. Microvessel counts were performed by examining the microvessels thoroughly in terms of count, morphology and density after staining the tissues by hematoxylin & eosin stain, reticulin and immunostain (Antifactor VIII Ag).
Results: On H&E stain - Microvessel density (MVD) in endometrial malignancy ranged from 3.0 - 13.5 and mean MVD was 8.78. On Reticulin stain - MVD ranged from 3.5 - 15.2 and mean MVD was 9.76. Antifactor VIII sections showed very small microvessels or even single endothelial cells with the highest total counts and the MVD ranged from 6.5-16.8 with Mean MVD of 11.7. The counts increased with the grade of the tumor in the absence of necrosis or haemorrhage. MVD counts also increased with the stage, being 8.12 in Stage I disease, 8.65 in Stage II and 10.8 in stage III disease. Atypical hyperplasia was found to be associated with epithelial tumors in 8 cases, making it a significant finding.
Conclusion: Role of angiogenesis assumes greater significance with increasing severity of lesions, higher grade and stage of the tumor and seems to have an important diagnostic and prognostic significance.
Background: Dilated cardiomyopathy is associated by radial and longitudinal contractile cardiac dysfunction. Left ventricular (LV) thrombus is a frequent finding in patients with dilated cardiomyopathy. The main purpose of our study was to evaluate the role of mitral annular plane systolic excursion (MAPSE) in LV thrombus formation in patients with dilated cardiomyopathy by assessing their correlation. Our additional objective was to compare the relationship of average MAPSE to relations of other LV features [LV size, LV ejection fraction (EF), wall motion score index (WMSI), sphericity index-width to length ratio (w/l) of the LV] and LV thrombus development.
Material and Methods: This was a prospective cross-sectional study conducted from October 2009 until January 2012 in 100 sinus rhythm patients with dilated cardiomyopathy without anticoagulation therapy. We excluded patients with: swallowing problems, acute myocardial infarction, atrial fibrillation/flutter, severe systolic dysfunction, severe arterial hypertension, valvular disease, and/or mechanical valves.
Results: Mean patient age was 58.1±12.7 years and 69% were men. Mean LV EF was 39.1±6.4%, while mean value of average MAPSE was 9.3±2.2mm. LV thrombus was detected in 14% of patients and its presence correlated well with: average MAPSE (r=-0.22, p=0.01), MAPSE of sepatal wall (r=-0.23, p=0.01), MAPSE of lateral wall (r=-0.2, p=0.02), MAPSE of inferior wall (r=-0.22, p=0.01), LV EF (r=-0.21, p=0.02), LV end diastolic diameter (r=0.24, p=0.008), LV end systolic diameter (r=0.31, p=0.0008), WMSI (r=0.22, p=0.01) and w/l (r=0.19, p=0.03).
Conclusions: Longitudinal LV dysfunction is associated with LV thrombus formation, as average MAPSE demonstrates a negative correlation with LV thrombus, and its role is similar to LV size, LV EF, sphericity index and WMSI.
Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drug-eluted stent (DES) era.
Study Design: A meta-analysis and systematic review.
Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012. We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization (TLR/TVR). Data was abstracted and analyzed by two independent reviewers and differences were resolved by consensus. We assessed the results for heterogeneity in our analysis by examining the forest plots and then calculating a Q statistic, which we compared with the I2 index. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model; otherwise the random-effects model was used.
Results: We identified 11studies involving 3,718 patients. Mean duration of follow-up was 29 months (range 12-62months). Compared with ostial and trunk stenting, distal LMCA PCI was associated with increased MACE (OR 1.95, 95% CI 1.43-2.66) and TLR/TVR (OR 3.13, 95% CI 1.90-5.16).No significant differences were detected for cardiac death (OR 1.06, 95% CI 0.72-1.58, p=0.58), MI (OR 1.15, 95% CI 0.74-1.77, p=0.80) or stent thrombosis (OR 1.57, 95% CI 0.90-2.77, p=0.41).
Conclusion: Patients with ostial and trunk LMCA lesions treated with DES have better outcomes than patients with distal lesions. Our findings may support unprotected non-distal LMCA stenting as a primary approach in selected patient subsets.
Aims: Vitamin D is known for its primary role in calcium and bone homeostasis and regulation of parathyroid hormone (PTH) secretion. There is increasing evidence for health benefits accomplished by activated vitamin D, that go beyond these classical functions. Previous studies have suggested that lower Vitamin D levels are associated with increased cardiovascular disease (CVD) risk. Therefore, we aimed to evaluate relationship between vit D levels and extent and severity of coronary artery disease. Study Design: Cross-sectional.
Place and Duration of Study: Sample: Department of Cardiology, Bagcilar Training and Research Hospital between November 2009 and march 2010.
Methodology: We evaluated 135 patients who underwent elective coronary angiography between November 2009 and march 2010. Patients with renal failure(GFR less than 60ml/min per 1.73m2), history of malignancy within the past 5 years, any predominant non-cardiac disease, patients using any vitamin D supplement or with hyperparathyroidism or hypercalcemia were excluded.
The severity and extent of CAD were determined using the Gensini score. And, patients were classified as having advanced (≥40) or mild (<40) CAD according to the Gensini scores.
Results: The mean 25-OH D concentration was 18.7ng/mL. The overall prevalence of 25-OH D less then 15ng/mL was 34,8%(n=47), with 11% having 25-OH D less then 10ng/mL. Multivariate analysis revaeled that smoking, presence of hyperlipidemia, higher CRP levels, higher ALP levels and low levels of 25-OH D concentrations were significantly associated with higher Gensini Scores.
Conclusion: In our study, we found significant correlation between low vitamin D levels and higher Gensini scores.
Aims: There is a general consensus in considering cigarette smoking as a major risk factor for cardiovascular diseases: a direct causal association between smoking and hypertension however is questioned. The present paper reports a study on the effect of cigarette smoking and of other clinical parameters on hypertension in a sample of subjects admitted to Hospital for Cardiovascular Diseases (CVD).
Study Design: Observational study.
Place and Duration of Study: Department of Cardiology Valmontone Hospital and Department of Biomedicine and Prevention, University of Rome Tor Vergata, between April 2007- December 2013.
Methodology: We have studied 335 subjects admitted to the Hospital for Cardiovascular Diseases. Statistical analyses were in the study that was approved by the Ethical Committee. We have considered hypertension in relation to smoking, diabetes, age and sex.
Results: Multivariate statistical analyses have shown a high significant effect of age (P<.001) and diabetes (P<.01) on hypertension and a border line effect of smoke (P=.05). No effect of sex has been detected (P=.47). The proportion of subjects with hypertension is positively correlated with the number of risk factors examined.
Conclusion: Our data indicate that an independent effect of smoking on blood pressure is relatively small and suggest an additive effect of the variables considered on the risk of hypertension.
Aims: Evidence is still lacking regarding optimal treatment for patients with heart failure with preserved ejection fraction (HfPEF). Our objective is to present an individual evaluation for each of the current available heart failure medications using a meta-analytical model.
Methods and Results: Using meta-analytical techniques we assessed the impact of standard systolic heart failure medications on the combined endpoint of all-cause mortality and/or hospitalization for heart failure as a primary endpoint and on mortality and heart failure hospitalization as separate secondary endpoints for patients with HfPEF. Studies were heterogeneous (Q test, p=0.01) and a random effect model was adopted for analysis. A total of 22 randomized and prospective observational studies of 16,802 patients were included; mean follow up duration was 27 months. Only angiotensin converting enzyme inhibitors (ACEIs) significantly reduced the composite end point of all-cause mortality and /or hospitalization for heart failure (HR 0.74 & 95% CI [0.61-0.89], p=0.01). As for all-cause mortality, only ACEIs (HR 0.57 & 95% CI [0.45-0.71], p=0.005), beta blockers (HR 0.63 & 95% CI [0.41-0.98], p=0.03) and statins (HR 0.41 & 95% CI [0.23-0.72], p=0.001) offered a survival benefit. As for hospitalization for heart failure, only digoxin had a significant effect (HR 0.77 & 95% CI [0.61-0.98], p=0.02).
Conclusions: Our analysis suggests that ACEI, beta blockers, statin and digoxin as potential medications that can improve outcomes in patients with HfPEF. However, prospective randomized studies are needed to better assess response to these medications.
Background: Iron deficiency (ID) has been shown to be linked with poor outcomes within heart failure (HF) populations in previous clinical trials. The impact of ID has not been evaluated in stable chronic heart failure (HF) patients in the community. Our objective was to study the role of ID in stable HF patients and its impact on short term survival.
Methods: In this study we analysed 512 patients with stable HF under the care of a regional nurse-led community heart failure team. The study started in June 2007 and ended in June 2010.
Results: There were 92% of patients on loop diuretics; 83% on ACE Inhibitors, 92% on b-blockers and 48% on aldosterone antagonists. Mean age of the patients was 77.9 years, 43% were females and mean NYHA class was 2.2. Absolute Iron deficiency (ID) and anemia were defined as ferritin <100µg/L and hemoglobin (Hb)<12g/dl, respectively. Mean Hb levels were 14.1; 13.9; 14.0 and 13.7g/dL at 0, 6, 12 and 24 months. Mean serum ferritin levels in the entire study population were 212µg/L at the start, and 197µg/L at the end. The prevalence of ID and anemia was 21.3% and 9.4%at the start, and was 21.5% and 8.4% at the end of the study. The prevalence of ID was 63%vs. 19% in subjects with vs. without anemia [p<0.001]. Risk-adjusted hazard ratios for 24-month mortality were 1.42 (95% confidence interval: 1.09-1.98) for ID and 1.05 (95% confidence interval; 0.87-1.51) for anemic patients respectively.
Conclusions: In our study, ID was prevalent in stable HF patients in the community and was linked with poor clinical outcomes. In addition, ID was a predictor for mortality than additionally to anemia.
Chocolate is made from the seeds of a tropical rainforest tree called “Theobroma cacao”. When compared with other food sources based on oxygen radical absorbance capacity (ORAC) measurement, dark chocolate is a major source of flavonols with highest antioxidant levels. Some of the health benefits of cocoa consumption include antioxidant properties such as polyphenolic compounds, among others are monomeric flavanols, epicatechin, catechin and oligomeric procyanidins. Both experimental and observational studies have suggested that chocolate consumption has a positive influence on human health, with antioxidant, antihypertensive, anti-inflammatory, anti-atherogenic, and anti-thrombotic effects as well as influence on insulin sensitivity, vascular endothelial function, and bioavailability of nitric oxide. In addition, dark chocolate consumption may alter lipid effects, by lowering total and low density lipoproteins and increasing high density lipoprotein cholesterol levels. The antioxidants found in chocolate have been shown to inhibit plasma lipid oxidation probably by scavenging free radical species. There are some experimental studies to prove that flavonoids could prevent LDL oxidation in vitro by scavenging radical species or sequestering metal ions. Dark chocolate (DC) has beneficial effects in the prevention of cardiovascular diseases (CVD) due to its anti-inflammatory and antioxidant properties. Polyphenols rich dark chocolate showed progress in insulin sensitivity and decreased blood pressure in healthy subjects. Dark Chocolate has a dual effect on platelets by decreasing platelet aggregation and also it reduces platelet adhesion. Chocolate extends its great beneficial effect from being by and large a palatable pleasant and hence sustainable therapeutic option. Thus, dark chocolate may be suggested as a potential delicacy and one of the agents for the prevention and control of cardiometabolic syndrome.
Atrial Fibrillation (AF) is the most common arrhythmia. AF is a major risk factor for stoke. Warfarin has been available for more than 60 years and until recently it was the only oral anticoagulant used for the prevention of stroke. Despite the extensive studies and proven efficacy, its utility is limited by multiple factors. Warfarin interacts with a multitude of drugs and foods, has a delayed onset of action, has a narrow therapeutic range, requires routine lab monitoring and exhibits variable responses in patients. The novel agents dabigatran, rivaroxaban and apixaban have the potential to have some of the limitations of warfarin. This article will discuss the pharmacokinetic and pharmacological considerations and different characteristics of the novel anticoagulants when used for the prevention of AF.