bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiofrequency catheter ablation of a right atriofascicular (mahaim) and two atrioventricular (kent) accessory pathways in a single session
Authors: Hluchy Jan , Wieczorek Marcus , Tekiyeh Mohsen , Jurkovicova Olga , Sabin Georg V.
Published: February 2009

This report describes the case of a 19‐year‐old patient with Ebstein's anomaly, who had an unusual combination of a right atriofascicular (Mahaim) and two ipsilateral right atrioventricular (Kent) accessory pathways participating in three types of antidromic and orthodromic reciprocating tachycardias in the absence of retrograde conduction over the bundle of His‐atrioventricular node axis. All three pathways were ablated in a single session using temperature‐guided radiofrequency current.
Provocation of coronary spasm by dobutamine stress echocardiography in a patient with angiographically minimal coronary artery disease
Authors: Deligonul Ubeydullah , Armbruster Robert , Hajlu Admassu
Published: February 2009

Dobutamine stress echocardiography (DSE) has been widely used for the noninvasive diagnosis of obstructive coronary artery disease. The ST‐segment elevation during DSE has been reported as an infrequent event, caused by old myocardial infarction and/or critical coronary narrowings. The patient presented here was a 35‐year‐old man with a recent history of nonexertional chest pain. He had hyperc‐holesterolemia and a history of heavy smoking as risk factors. The patient developed ST‐segment elevation with chest pain during 40 mcg/min dobutamine infusion for the stress echocardiographic examination. Subsequent coronary angiograms revealed only mild coronary atherosclerosis. It is speculated that coronary spasm occurred in this patient as a paradoxical response to increased coronary blood flow with dobutamine administration.
Complications of pharmacologic stress echocardiography in coronary artery disease
Authors: Bigi Riccardo
Published: February 2009

In the last few years, pharmacologic stress echocardiography is emerging as a promising diagnostic tool with a favorable cost/benefit ratio. Its main clinical applications include the assessment of coronary artery disease, the identification of viable myocardium, and risk stratification before major vascular surgery. However, cardiac (arrhythmic, ischemic, or hemodynamic) as well as noncardiac complications have been reported, so that a risk/benefit analysis is advisable in view of the extensive introduction of this technique in the clinical arena. The most popular pharmacologic agents employed for stress echocardiography are dipyridamole, do‐butamine, and adenosine. A comparative analysis with exercise stress testing, the classical standard of reference of all ischemia‐provoking tests, confirms that in terms of safety and tolerability pharmacologic stress echocardiography may be considered a good alternative in patients unable to exercise maximally. No appreciable difference among the safety profiles of the most common pharmacologic agents has been found, but a careful evaluation of the risk/benefit ratio is advisable for any stressor in the individual patient by considering the relative importance of the expected diagnostic contribution and the pharmacodynamic impact of the test. Finally, adequate training of the operator and monitoring of the patient during stress and recovery are essential for getting optimal safety conditions.
Effect of the stress level achieved during symptom‐limited exercise technetium‐99m sestamibi myocardial tomography on the detection of coronary artery disease
Authors: Stratmann Henry G. , Younis Liwa T. , Wittry Mark D. , Amato Maryellen , Mark Alexander L. , Douglas Miller D.
Published: February 2009

Background: The stress level achieved during exercise thallium‐201 myocardial imaging may influence its sensitivity for detecting coronary artery disease (CAD). The effect of exercise adequacy on the accuracy of technetium‐99m sestamibi (MIBI) imaging has not been studied.

Hypothesis: The study was undertaken to assess the effect of exercise level achieved on sensitivity for detecting CAD.

Methods: A consecutive series of 250 patients (mean age 60 ± 10 years) with CAD by angiography underwent symptom‐limited exercise MIBI single‐photon emission computed tomography. Single‐vessel CAD was found in 66 patients, double‐vessel CAD in 84, triple‐vessel CAD in 80, and left main disease in 20.

Results: No significant differences were found in sensitivities of an abnormal MIBI scan or a reversible defect among 102 patients reaching 85% of age‐predicted heart rate and 148 who did not (82 vs. 89% and 66 vs. 70%, respectively, p = NS). Patients (n = 128) able to exercise ≤6 min had a higher incidence of abnormal scans and reversible defects than 122 patients with a greater exercise duration (91 vs. 82% and 75 vs. 61 %, respectively, both p<0.05). Sensitivity of an abnormal MIBI scan for multivessel disease was greater than for single‐vessel disease in patients who achieved ≥85% of age predicted heart rate (91 vs. 59%, p<0.01) and in those who exercised >6 min (89 vs. 66%, p<0.01). No significant differences in the sensitivities of an abnormal MIBI study for multivessel versus single‐vessel CAD were seen in patients achieving lower peak levels of exercise. Sensitivity of ischemic ST depression was lower than that of MIBI tomography at all levels of exercise.

Conclusions: The sensitivity of exercise MIBI tomography for angiographic CAD is relatively independent of the peak heart rate achieved. Exercise duration of >6 min is associated with a significantly higher MIBI abnormality rate than a duration of >6 min, possibly reflecting the effect of myocardial ischemic burden on exercise ventricular function. Regardless of level of stress or its duration, exercise MIBI tomography improves the sensitivity for CAD detection compared with stress‐induced ischemic ST depression.
Pneumococcal pericarditis—Out of sight, out of mind?
Authors: Mcmechan Stephen R. , Cochrane David , Jennifer Adgey A.A.
Published: February 2009

Pneumococcal pericarditis has been an uncommon condition in recent years. This report describes the case of a 57‐year‐old woman with sarcoidosis who presented with cardiac tamponade due to pneumococcal pericarditis. She responded to pericardiocentesis and intravenous antibiotic therapy. At 4‐month review, she remains well.
Myocardial contusion caused by a baseball
Authors: Mirukawa Masaru , Hirose Kunihiko , Mori Tatsuhiko , Kusukawa Jyunya , Tomioka Nobuyoshi , Watanabe Yutaka
Published: February 2009

Myocardial contusion is a rare type of sports injury. We report a case of myocardial contusion caused by a baseball. In this patient, arrhythmias were induced by an exercise test 1 week after injury. That patients with myocardial contusion but without arrhythmias at rest need to be treated carefully is emphasized.
Ethanol sclerosis can be a safe and useful treatment for pericardial cyst
Authors: Kinoshita Yoshihisa , Shimada Toshio , Murakami Yo , Sano Kazuaki , Tanabe Kazuaki , Ishinaga Yuji , Kato Harumi , Murakami Rinji , Morioka Shigefumi
Published: February 2009

We report the case of a 41‐year‐old man with a pericardial cyst treated by percutaneous aspiration and ethanol injection. He was referred to our hospital because of elec‐trocardiographic abnormality. On admission, chest x‐ray revealed a large pericardial cyst in the right cardiophrenic angle. The cyst was examined by echocardiograpy, computed tomography, and cytological analysis of aspiration fluid from the cyst. Ethanol sclerosis was applied for treatment of the cyst, which had continued to increase in size. There was no recurrence of the cyst 6 months after the treatment. Percutaneous ethanol sclerosis can be the first choice of treatment for pericardial cyst.
The evolution of today's hospital emergency departments —Current problems and challenges
Authors: Mcintosh Henry D.
Published: February 2009

The announcement of the National Heart Attack Alert Program by the National Heart, Lung and Blood Institute in June of 1991 prompted leaders of the Florida Chapter of the American College of Cardiology to develop a statewide program to reduce the morbidity and mortality from acute myocardial infarctions within Florida. It became apparent that the success of such a program would require the prompt institution of thrombolytic agents or other revascular‐ization procedures in appropriate patients. No longer could the decision regarding institution of therapy await discussion by telephone and/or the arrival at the emergency department (ED) of the patient's primary care physician or cardiologist. Efforts to establish appropriate protocols for therapy revealed that many of the 25,000 or more physicians currently staffing the 5,600 or so EDs in this country were moonlighting residents or practitioners from a variety of specialties or subspe‐cialties with limited or no formal EM training. Furthermore, it was learned that there were in the entire country only about 800 postgraduate, year‐one Council for Graduate Medical Education accredited training positions. There were only 21 such training positions in the entire state of Florida. The reasons for these deficiencies are discussed and a challenge to correct this person power crisis is issued, not principally to the leadership of EM, but to the entire medical profession.
Cardiopulmonary determinants of functional capacity in patients with chronic heart failure compared with normals
Authors: Meyer Katharina , Westbrook Samuel , Schwaibold Matthias , Hajric Ramiz , Roskamm Helmut , Lehmann Manfred
Published: February 2009

Background: Patients with chronic heart failure (CHF) are characterized by abnormal gas exchange and ventilatory responses to exercise.

Hypothesis: This study compares variables obtained from cardiopulmonary exercise testing in 35 patients with CHF with 35 age‐ and weight‐matched healthy subjects. A second goal was to obtain cardiopulrnonary variables measured at ventilatory threshold to distinguish patient changes from those of healthy subjects.

Methods: Exercise testing was carried out using bicycle ergometry with ramplike protocol (work rate increments 12.5 W/min). Gas exchange and ventilation were measured breath by breath.

Results: Compared with healthy subjects, the VO2 in patients was lower at identical work rates (p<0.004) and at ventilatory threshold (p<0.0001), and the slope of the VO2 curve during incremental exercise was flatter (p<0.05). With the exception of heart rate, the variables for VO2, VCO2, ventilation, O2 pulse, ventilatory equivalents for O2 and CO2, and Vd/Vt (physiologic deadspace to tidal volume ratio), as well as lactate differed significantly at identical work rates. With the exception of Vd/Vt, all cardiopulmonary variables showed significant differences in their slopes during exercise. By means of a discriminant analysis, VCO2 and ventilation proved to be the most distinguishing variables at ventilatory threshold between patients with CHF and healthy subjects.

Conclusions: These results indicate the clinical usefulness of cardiopulmonary exercise testing when assessing functional impairment due to CHF. For treatment evaluation, not only VQ2 but also VCO2 and ventilation responses to exercise should be considered.
Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part IV
Authors: Waller Bruce F. , Orr Charles M. , Vantassel James , Peters Thomas , Fry Edward , Hermiller James , Grider Larry D.
Published: February 2009

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part IV of this six‐part series focuses on morphologic correlates of coronary angiographic patterns of remodeling after balloon angioplasty and discusses effects of angioplasty on adjacent, nondilated vessels.
The effect of atrial fibrillation and the ventricular rate control on exercise capacity
Authors: Ostermaier Ralf H. , Dalla Vecchia Laura , Lampert Steven , Ravid Shmuel
Published: February 2009

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting approximately 1.5 million patients in the United States.

Hypothesis: This study was designed to determine the effect of AF and the ventricular rate control during AF on cardiovascular performance as measured by exercise endurance on a standard Bruce protocol.

Methods: Sixty‐three patients with AF who underwent exercise stress testing during both sinus rhythm and AF were analyzed. Heart rate, blood pressure, heart rate acceleration, exercise duration, and left ventricular (LV) systolic function were measured.

Results: Atrial fibrillation resulted in a small but statistically significant decrease in exercise endurance (426 ± 180 vs. 402 ± 168 s, p < 0.05). The drop in exercise tolerance was consistent regardless of the underlying heart condition or adequate ventricular rate control during AF. Heart rate in AF was consistently faster than in sinus rhythm, at rest, and at peak exercise (63 vs. 79 beats/min and 125 vs. 149 beats/min, respectively, p < 0.001).

Conclusion: Our analyses indicated that (1) the loss of atrioventricular synchrony had minimal effect on cardiovascular performance in patients with preserved LV function, (2) the decrease in cardiovascular performance was related to loss of atrioventricular synchrony but not to underlying heart disease or ventricular rate control, and (3) compensation for the loss of the atrial contribution was provided by consistently faster heart rate during AF.
Effect of amiodarone on qt dispersion in the 12‐lead standard electrocardiogram and its significance for subsequent arrhythmic events
Authors: Grimm Wolfram , Steder Ulrike , Menz Volker , Hoffmann JÜRgen , Maisch Bernhard
Published: February 2009

Background and hypothesis: QT dispersion, measured as interlead variability of QT intervals in the surface electrocardiogram, has been demonstrated to provide an indirect measurement of the inhomogeneity of myocardial repolarization. The purpose of the present study was twofold: (1) to analyze the effect of amiodarone on QT dispersion measured in the 12‐lead standard ECG, and (2) to examine the association between QT dispersion on amiodarone and subsequent arrhythmic events.

Methods: To determine the effect of amiodarone on QT dispersion and its clinical significance for subsequent arrhythmic events, QT dispersion was measured in the 12‐lead standard electrocardiogram (ECG) in 52 patients before and after administration of empiric amiodarone for ventricular tachyarrhythmias.

Results: QT intervals increased from 401 ± 44 ms before amiodarone to 442 ± 53 ms after amiodarone therapy, and rate corrected QT intervals (QTc) increased from 452 ± 43 ms to 477 ± 37 ms, respectively (p<0.01). QT dispersion, QTc dispersion, and adjusted QTc dispersion, which take account of the number of leads measured, were not significantly different before and after initiation of amiodarone therapy (58 ± 24 ms vs. 61 ± 26 ms, 68 ± 29 vs. 66 ± 26 ms, and 22 ± 8 vs. 22 ± 8 ms, respectively, p = NS). During 31 ± 25 months follow‐up after initiation of amiodarone therapy, arrhythmic events defined as sustained ventricular tachycardia, ventricular fibrillation, or sudden death occurred in 11 of 52 study patients (21%). QT dispersion, QTc dispersion, and adjusted QTc dispersion on amiodarone were not different between patients with and without arrhythmic events during follow‐up (65 ± 14 vs. 59 ± 29 ms, 73 ± 15 vs. 64 ± 28 ms, and 25 ± 6 vs. 21 ± 8 ms, respectively, p=NS).

Conclusions: We conclude that (1) amiodarone increases QT intervals and QTc intervals during sinus rhythm but does not significantly change measures of QT dispersion; and (2) QT dispersion measured in the 12‐lead standard ECG after initiation of amiodarone therapy does not appear to be a useful marker for subsequent arrhythmic events.
Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part VI
Authors: Waller Bruce F. , Orr Charles M. , Vantassel James , Peters Thomas , Fry Edward , Hermiller James , Grider Larry D.
Published: February 2009

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part VI of this six‐part series focuses on atherectomy and restenosis tissue obtained by atherectomy procedures.
Clinical relevance of heart rate variability
Authors: Kautzner Josef , John Camm A.
Published: February 2009

Heart rate variability (HRV) has recently become a popular noninvasive research tool in cardiology. Clinical assessment of HRV is frequently based on standard long‐term ambulatory electrocardiograms, whereas physiologic studies employ spectral analysis of short‐term recordings under controlled conditions. From a general point of view, HRV can be used in clinical practice to estimate (1) the integrity of cardiac autonomic innervation, (2) the physiologic status of cardiac autonomic activity, and (3) the vulnerability to various cardiac arrhythmias resulting from autonomic imbalance. Clinical relevance of HRV has been clearly demonstrated in only two clinical conditions: (1) impaired HRV can be used alone or in a combination with other factors to predict risk of arrhythmic events after acute myocardial infarction, and (2) decrease in HRV is a useful clinical marker for evolving diabetic neuropathy. Substantial advances of our knowledge are required to establish and promote clinical applications in other areas of clinical medicine. To accomplish this task, proper hypotheses should be studied and appropriate techniques selected.
Enhanced external counterpulsation as an adjunct to revascularization in unstable angina
Authors: Lawson William E. , Cohn Peter F. , Burger Lynn , Katz Jordan P. , Dervan John P. , Zheng Zhen Sheng , Oster Zvi H. , Cabahug Corazon , Hui John C. K. , Jiang Lixin , Soroff Harry S.
Published: February 2009

Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic stable angina. Despite intensive risk factor modification, a patient required two surgical coronary revascularizations and seven multivessel angioplasties over a 26‐monfh period, demonstrating recurrent unstable angina and persistent thallium perfusion defects despite revascularization. Post EECP, angina was relieved, thallium defects were resolved, and the patient has remained asymptomatic for 36 months.
Heart rate variability as a measure of autonomic nervous system function in anorexia nervosa
Authors: Petretta Mario , Bonaduce Domenico , Themistoclakis Sakis , Ianniciello Angiolino , Scalfi Luca , De Filippo Emilia , Contaldo Franco , Marciano Fortunato , Migaux Marie‐Louise
Published: February 2009

Background and hypothesis: Alteration in sympathovagal balance may be a mechanism of increased cardiovascular mortality and sudden death of patients with anorexia nervosa. This study was undertaken to characterize cardiac autonomic control in patients with anorexia nervosa by means of heart rate variability analysis.

Methods: Heart period variability by 24‐h Holter recording was evaluated in 13 young women with anorexia nervosa, 10 constitutionally thin women, and 10 women of normal weight.

Results: High‐frequency power, a measure of parasympathetic modulation of heart rate, and all‐time domain measures of heart rate variability were higher in patients with anorexia nervosa than in thin women and in those of normal weight. Thin women showed lower values of total power and of most components of power spectrum.

Conclusions: Our data demonstrate an increased vagal tone in young women with anorexia nervosa. The marked increase in parasympathetic activity, not in response to an increase in sympathetic activity, could be detrimental and may contribute to the higher cardiovascular mortality of these patients.
Cardiac dysfunction in patients with chronic progressive external ophthalmoplegia
Authors: Akaike Masashi , Kawai Hisaomi , Yokoi Kenji , Kunishige Makoto , Mine Hideki , Nishida Yoshihiko , Saito Shiro
Published: February 2009

Background: Chronic progressive external ophthalmoplegia (CPEO), which includes Kearns‐Sayre syndrome, is a mitochondrial disorder with large deletions of mitochondrial DNA. Recently, mtDNA deletions in cardiac muscle cells were thought to be a cause of dilated cardiomyopathy. However, the cardiac involvement in patients with CPEO is generally considered to be limited to the cardiac conduction system.

Hypothesis: The purpose of this study was to evaluate left ventricular function in patients with CPEO.

Methods: We evaluated the cardiac function of five patients with CPEO by means of carotid pulse recording and Doppler echocardiography.

Results: The ratio of the pre‐ejection period to ejection time was increased to 0.67 in one patient and to 0.50 in another. Echocardiography showed left ventricular dilatation and diffuse hypokinetic wall motion in both cases. Left ventricular fractional shortening was decreased to 5 and 19%, respectively, and the mean rate of circumferential shortening was decreased to 0.12 and 0.63 circ/s, respectively. One of the two patients died of congestive heart failure 2 months after the study. The Doppler pattern of left ventricular filling in the three remaining patients showed a decrease in the ratio of peak flow velocity in early diastole to that in late diastole, with an increase in deceleration time.

Conclusion: Although cardiac involvement in patients with CPEO is generally considered to be limited to the cardiac conduction system, left ventricular dysfunction may be present and should receive more attention in the management of patients with CPEO.
Association between psychiatric disorders and marfan's syndrome in a large sardinian family with a high prevalence of cardiac abnormalities
Authors: Mercuro Giuseppe , Ruscazio Massimo , Zoncu Sandra , Montisci Roberta , Cherchi Angelo , Carpiniello Bernardo , Rudas Nereide
Published: February 2009

Background: Marfan's syndrome is an inherited disorder of connective tissue associated with characteristic abnormalities of the skeletal, ocular, and cardiovascular systems. Marked clinical variability and age dependency of all manifestations of Marfan's syndrome may render the unequivocal diagnosis difficult in mildly affected, young subjects.

Hypothesis: The study and care of a 32‐year‐old woman with evidence of Manfan's syndrome, several cardiac abnormalities, and paranoid schizophrenia led to an investigation of her consenting relatives to verify the penetrance of Marfan's syndrome and the degree of comorbidity between the disease and psychiatric disorders.

Methods: The patient and 12 subjects belonging to three generations of her family underwent cardiovascular, skeletal, ophthalmologic, and psychiatric examinations. Two‐dimensional and Doppler echocardiography were performed.

Results: One female index patient and six of her first‐degree relatives were found to be affected by Marfan's syndrome. All seven patients were found to have mitral valve prolapse associated with other cardiac abnormalities. Four of these patients were affected by the following psychiatric disorders: generalized anxiety disorder, major depressive disorder, paranoid schizophrenia (two cases). Six more relatives without Marfan's syndrome showed mitral valve prolapse in association with other echocardiographic features. Two of these were found to be affected by a major depressive disorder.

Conclusions: The present data support the hypothesis that a psychiatric condition, associated with a significantly high frequency of cardiac involvement, may be part of the phenotype of Marfan's syndrome.
Transesophageal echocardiographic detection of cardiac embolic source in cor triatriatum complicated by aortic saddle emboli
Authors: Huang Tsuei‐Yuen , Sung Ping‐Hsiun
Published: February 2009

Transesophageal echocardiographic findings are described in a case of cor triatriatum with atrial fibrillation complicated with cerebral and aortic saddle emboli. A spontaneous echo contrast confined to the dilated proximal chamber of the left atrium was noted and was presumed to be the embolic source in cor triatriatum.
Diffuse pulmonary hemorrhage complicating thrombolytic therapy for acute myocardial infarction
Authors: Gopalakrishnan Deepika , Tioran Teresa , Emanuel Carlos , Clark Vivian L.
Published: February 2009

Diffuse pulmonary hemorrhage has rarely been reported as a complication of thrombolytic therapy. Recently, two patients who developed this complication were observed at our institution. This diagnosis should be considered in any post‐thrombolytic patient with respiratory distress, diffuse pulmonary infiltrates, and an otherwise unexplained fall in hemoglobin.
Pericardial involvement in acute myocardial infarction in the post‐thrombolytic era: Clinical meaning and value
Authors: Correale Ernesto , Romano Salvatore , Ricciardiello Vincenzo , Battista Rossano , Maggioni Aldo P. , Santoro Eugenio
Published: February 2009

Pericardial involvement (PI) in acute myocardial infarction (AMI) is a complication usually considered benign and has therefore received less attention than those more severe. It may be easily missed because it presents few symptoms and signs, which in turn may be confused with those of AMI. Its path physiology, diagnosis, and pitfalls are discussed. The GISSI‐1 trial revealed a marked reduction of PI in the group treated with thrombolysis. This unexpected finding was later confirmed by the GISSI‐2 trial and by other studies, drawing attention to its meaning. Data from the GISSI as well as from other studies have been reviewed and seem to indicate that PI is associated with larger AMIs and with a significant increase in 6‐ and 12‐month mortality. This may be attributed to the consequences of late remodeling of a large infarction. These findings lead to the conclusion that PI should be granted more attention, and that it might identify patients with a poorer long‐term outcome.
Arrhythmogenic right ventricular cardiomyopathy: a survey of the investigations at the university of padua
Authors: Basso Cristina , Thiene Gaetano , Nava Andrea , Dalla Volta Sergio
Published: February 2009

The purpose of this paper is to review the history of the clinico‐pathologic investigations performed at the University of Padua on an old morbid entity (“parchment heart”), which, in the 1960s, led to the clinical description of the disease, in the 1980s to the revival of the scientific interest, and in the mid 1990s to the understanding of the genetic background. All the steps of the progressive knowledge are reviewed: necropsy of young people who died suddenly, in vivo diagnosis by ECG, echocardiography, angiocardiography, endomyocardial biopsy, nuclear magnetic resonance, and diagnostic criteria. Familial occurrence with autosomic dominant transmission and various penetrance was documented. Gene defects were recently mapped both to chromosome 14q23–q24 and 1q42–q43, thus providing evidence for genetic heterogeneity. The pathologic substrates of arrhythmogenic right ventricular cardiomyopathy pointed to an acquired progressive myocardial atrophy with fibro‐fatty replacement of dying myocytes. Nowadays the disease is definitively regarded as a primary myocardial disorder and it has been included in the revised WHO classification of cardiomyopathies.
Factors influencing heart rate variability in patients with severe aortic valve disease
Authors: Jung Jens , Heisel Armin , Butz Bernhard , Fries Roland , Schieffer Hermann , Tscholl Dietmar , Schäfers Hans‐Joachim
Published: February 2009

Background and hypothesis: Heart rate variability (HRV) is an accepted tool for the assessment of cardiovascular autonomic tone. There are no sufficient data concerning its application to patients with severe aortic valve disease (AVD) requiring cardiac surgery.

Methods: It was the aim of this study to examine HRV and its physiologic correlates in patients with severe aortic valve disease requiring cardiac surgery. The correlates of time domain indices of HRV obtained from 24‐h Holter electrocardiographic recordings were analyzed in 36 consecutive patients (23 men and 13 women, mean age 62 ± 11 years) with AVD prior to cardiac surgery (aortic stenosis: 17 patients, aortic valve regurgitation: 3 patients, combined aortic valve disease: 16 patients).

Results: Low values of HRV were found in the entire study group: SDNN 96.8 ± 30.9 ms, SDNNI 39.3 ± 14.4 ms, SDANN 86 ± 28.9 ms, and RMSSD 30 ± 18.1 ms. In a univariate analysis, there was no significant correlation between the time domain measures of HRV and age, gender, medication, left ventricular ejection fraction, peak aortic pressure gradient, fraction of aortic valve regurgitation, and left ventricular mass assessed by echocardiography. Patients in advanced functional classes of heart failure [New York Heart Association (NYHA) III or IV] had significantly lower values for SDNN (83.8 ± 33.6 vs. 107.3 ± 24.7 ms; p<0.05) and SDANN (72.7 ± 29.4 vs. 96.6 ± 24.3 ms; p<0.05) than patients in NYHA class I or II. Reassessment of HRV 1 week after aortic valve replacement was performed in 17 patients and showed a significant further decrease of SDNN (102.4 ± 29.7 vs. 61.5 ± 23.5 ms; p<0.001), SDNNI (40.7 ± 13.6 vs. 23.4 ± 12.4 ms; p<0.001) and SDANN (91.8 ±29.2 vs. 54.2 ± 22.8 ms;p<0.001).

Conclusion: Patients with AVD requiring cardiac surgery reveal reduced time domain indices of HRV. This observation is pronounced in patients with a progressed clinical class of heart failure, whereas hemodynamic and echocardiographic parameters seem to have no significant influence on HRV parameters in this population. In addition, there is evidence of a further reduction of HRV time domain indices 1 week after uncomplicated aortic valve replacement.
Culprit lesion and jeopardized myocardium: Correlation between coronary angiography and single‐photon emission computed tomography
Authors: Candell‐Riera Jaume , Domingo Enric , Permanyer‐Miralda GaietÀ , Soler‐Soler Jordi , Olona‐Cabases Montserrat , Santana‐Boado CÁSar , Castell‐Conesa Joan , Aguadá‐Bruix Santiago
Published: February 2009

Background: The term “culprit lesion” is used to designate the coronary stenosis responsible for the symptoms of the patient with coronary artery disease. Its detection is essential when partial revascularization is contemplated. The term “jeopardized myocardium” is commonly used to mean the amount of myocardium put in danger by all the stenotic lesions; however, it should be restricted to the amount of myocardium that could become infarcted if only the most severe stenoses were occluded.

Hypothesis: The aim of this study was to investigate (1) the agreement between coronary myocardial single‐photon emission computed tomography (SPECT) and coronary angiography for the identification of the culprit lesion, and (2) the correlation of the two studies in the quantification of jeopardized myocardium.

Methods: In all, 159 patients with coronary artery disease without previous myocardial infarction were included in the study. A score for myocardial SPECT was correlated with the angiographic scores by Califf and Gensini and with the authors' score which includes adjustment for collateral circulation.

Results: The agreement between coronary angiography and SPECT for the diagnosis of the culprit lesion was 84% (87/104). The correlations between the scores of angiography and SPECT to assess jeopardized myocardium when all coronary stenoses were taken into account were significant (p<0.0001), but their coefficients were suboptimal (r = 0.48 for Califf, r = 0.48 for Gensini, and r = 0.65 for the authors' score). When only the jeopardized myocardium resulting from the culprit lesion was considered, the correlation clearly improved (r=0.85).

Conclusion: Thus, in 84% of patients with multivessel disease, an agreement between coronary angiography and myocardial SPECT for the diagnosis of the culprit lesion was observed. The correlation between these techniques for the quantification of jeopardized myocardium from the culprit lesion was satisfactory.
Comparison between dobutamine echocardiography and thallium‐201 scintigraphy in detecting residual stenosis, ischemia, and necrosis in patients with prior myocardial infarction
Authors: Macieira‐Coelho Eduardo , Dionísio Isabel , Garcia‐Alves MÁRio , Cantinho Guilhermina , Da Costa Brás B. , Gouveia AntÓNio , De Pádua Fernando
Published: February 2009

Background: Following the first attempts to detect myocardial ischemia with two‐dimensional echocardiography stress testing, pharmacologic stress using dobutamine infusion has become an alternative to echocardiography exercise testing for evaluation of coronary artery disease. It has been shown that stress echocardiography has a diagnostic accuracy similar to that of an exercise thallium test. Other studies, however, indicated that radionuclide myocardial perfusion imaging was more sensitive than exercise or pharmacologic stress echocardiography for detection of ischemia or jeopardized myocardium.

Hypothesis: The aim of the present study was to determine the ability of dobutamine stress echocardiography in comparison with thallium‐201 scintigraphy to identify multivessel disease and the presence of myocardial scar and ischemia in 60 consecutive patients who suffered a first myocardial infarction (MI).

Methods: Patients were evaluated by coronary angiography and ventriculography, thallium‐201 (201Tl) tomographic scintigraphy, and dobutamine echocardiography within 3 months of a first MI. Forty‐seven had Q‐wave MI and 13 had non‐Q‐wave MI. Eleven patients were excluded from final analysis—7 because of failure to achieve target heart rate in spite of the use of atropine, and 4 because of high blood pressure following the infusion of dobutamine.

Results: Dobutamine echocardiography showed an overall sensitivity of 43% for detection of coronary artery lesions of 50–74% diameter stenosis and 201Tl scintigraphy showed a sensitivity of 71%. For detection of lesions of ≥75% diameter stenosis, dobutamine echocardiography showed a sensitivity of 52% and 201Tl a sensitivity of 70%. Overall agreement between wall motion and myocardial perfusion for detection of necrosis and/or ischemia in the infarct area was 40.4% with a kappa coefficient of 0.09 (p = 0.13). For detection of ischemic myocardium outside the infarct zone, overall agreement was 78.6% with a kappa coefficient of 0.49 (p<0.0001).

Conclusion: Dobutamine echocardiography results showed a lower sensitivity than myocardial perfusion images in predicting multivessel coronary artery disease, and there was poor agreement between both methods in identifying necrosis or ischemia.
Long‐term low‐dose amiodarone therapy in the management of ventricular and supraventricular tachyarrhythmias: Efficacy and safety
Authors: Lee KäThy L. , Tai Yau‐Ting
Published: February 2009

Background: Amiodarone hydrochloride has been in use for two decades for the control of ventricular and supraventricular arrhythmias. Established and emerging evidence indicates that amiodarone has an antiarrhythmic efficacy superior to that of most other drugs.

Hypothesis: The study was undertaken to evaluate the efficacy and acceptability of low‐dose amiodarone therapy in the long‐term management of supraventricular and ventricular tachyarrhythmias.

Methods: A total of 124 patients with symptomatic drug‐refractory or life‐threatening arrhythmias managed with low‐dose oral amiodarone therapy over a 10‐year period was analyzed retrospectively. Of these, 45 patients (36%) had ventricular arrhythmias, 52 (42%) had atrial arrhythmias, and 27 (22%) had atrioventricular reentry tachycardia. Loading doses of amiodarone 600 mg daily for 1 week were administered for supraventricular arrhythmias and 600–1200 mg daily for 2 weeks for ventricular arrhythmias. Maintenance daily doses were 194 ± 48 and 206 ± 55 mg, respectively. Mean treatment duration was 32 ± 28 months, with 326.3 patient years of therapy.

Results: Of 39 patients with sustained ventricular tachyarrhythmias, the actuarial incidence of satisfactory arrhythmia control (absence of sudden cardiac death or nonfatal arrhythmia recurrence) was 78% at 1 year and 71 % at 2 years. Satisfactory control of supraventricular arrhythmias (mean ventricular rate < 100/min with significant symptomatic improvement for sustained atrial arrhythmias and < 1 attack per year for paroxysmal atrial or atrioventricular arrhythmias) was achieved in 73, 65, and 62% of patients at 1, 2, and 3 years, respectively. The cumulative incidence of amiodarone‐related adverse effects was 5.8 per 100 patient years, with drug withdrawal required in 12 patients (9.7%). Fifteen patients had thyroid dysfunction, 2 had hepatic toxicity, and 1 developed nonfatal pulmonary fibrosis. Overall, the incidence of successful use of amiodarone (satisfactory arrhythmia control and freedom from side effects) was 67, 59, and 53% at 1, 2, and 3 years, respectively.

Conclusions: The results of this study suggest that the efficacy of low‐dose amiodarone therapy in the management of serious ventricular and supraventricular arrhythmias would be similar to those achieved with higher doses, but with a much more acceptable side effect profile.
Natural history of asymptomatic valvar pulmonary stenosis diagnosed in infancy
Authors: Anand Rajani , Mehta Ashok V.
Published: February 2009

Background and hypothesis: Valvar pulmonary stenosis is a common congenital heart defect. Progression of stenosis over time, even when mild initially, has been shown by serial cardiac catheterization studies in children and adults. We studied the natural history of asymptomatic valvar pulmonary stenosis diagnosed in infancy with two‐dimensional echocardiography and Doppler method.

Methods: Between November 1986 and March 1993, 51 infants in the Northeast Tennessee and Southwest Virginia region were clinically diagnosed to have isolated valvar pulmonary stenosis. In 40 patients, the diagnosis was confirmed by two‐dimensional echocardiogram/Doppler and color‐flow mapping study at the time of presentation, and only their course is reported. Of 40 infants, six asymptomatic infants (15%) showed rapid progression of pulmonary stenosis over a relatively short period of time. Within the first 6 months of life, three of the six infants showed worsening of the stenosis needing intervention (one had surgical valvectomy and the others had percutaneous balloon valvuloplasty). The three other infants showed a more gradual increase of pulmonary stenosis over the first 2 years of life.

Results: Pulmonary stenosis even when mild can worsen in infancy, and it is not possible to predict which patients will follow this course. In our group of asymptomatic infants with initial mild pulmonary stenosis, 15% developed significant stenosis that needed intervention.

Conclusion: We recommend frequent follow‐up of asymptomatic infants with mild pulmonary stenosis during the first 2 years of life to detect rapid progression that may need intervention.
Is computer interpretation of the exercise electrocardiogram a reasonable surrogate for visual reading?
Authors: Malik Marek , Mickelson Judith K. , Bates Eric R. , Hartigan Pamela , Folland Edward D. , Parisi Alfred F.
Published: February 2009

Background: Interpretation of exercise tests as positive or negative is primarily based upon exercise‐induced ST segment changes. Consistently accurate measurements are difficult to obtain during exercise.

Hypothesis: This study compared on‐line computer‐generated electrocardiographic (ECG) analysis with visual interpretation. The goals were to document the extent of agreement, establish reasons for disagreements, characterize ST‐segment depression (extent, onset, duration), and determine the sensitivity and ability to localize coronary artery disease for each method.

Methods: Comparisons were made in 120 patients at eight Veterans Affairs Medical Centers. An exercise test was considered positive if > 1.0 mm horizontal or downsloping ST‐segment depression was detected 0.08 s after the J point during exercise or recovery. The ST‐segment depression had to be present on at least two successive ECG recordings 15 s apart. Computer interpretation was based on median averaged beats.

Results: There was an 88% agreement of visual and computer interpretations [106/120 (both positive, n = 62; both negative, n = 44)]. The disagreements involved visual negative, computer positive in 10 cases and visual positive, computer negative in 4 cases. Correlation was excellent between methods for characterization of ST‐segment depression (p<0.0001). Sensitivity for detecting and the ability to localize coronary artery disease (≥70% stenosis) were similar for both methods.

Conclusion: This computer algorithm using median averaged beats is a reasonable surrogate for visual interpretation of the exercise ECG, making it a valuable source of confirmation of physician readings in large research trials and in clinical settings.
Coronary risk factors, endothelial function, and atherosclerosis: A review
Authors: Vogel Robert A.
Published: February 2009

The traditional risk factors for coronary heart disease, which include hypercholesterolemia, hypertension, cigarette smoking, diabetes mellitus, and high‐fat diet, have all been associated with impairments in endothelial function. Impaired endothelium function may promote the development of atherosclerosis through its effects on vasoregulation, platelet and monocyte adhesion, vascular smooth muscle cell growth, and coagulation. Increased oxidative stress may be another mechanism by which endothelial dysfunction contributes to atherosclerosis, although controversy exists on this issue. Risk factor modification, particularly lowering elevated concentrations of low‐density lipoprotein cholesterol, improves endothelial function. At least seven clinical studies have demonstrated improved endothelial function with cholesterol reductions in patients with markedly elevated or even borderline elevations in cholesterol concentrations, whether or not coronary heart disease is present. Other interventions that improve endothelial function include blood pressure reduction, smoking cessation, and administration of estrogen to postmenopausal women.
Cannulation of the coronary sinus via the femoral vein—A new technique
Authors: Katritsis Demosthenes , Webb‐Peploe Michael M.
Published: February 2009

Background: Cannulation of the coronary sinus usually has been accomplished by advancing a catheter through the subclavian or internal jugular veins.

Hypothesis: We have developed a new technique for cannulation of the coronary sinus with a modified 6F Judkins L5 coronary catheter positioned through the femoral vein.

Results: The technique was tried successfully in 20 consecutive patients by the same operator and the average fluoroscopy time for coronary sinus cannulation was 1.6 ± 1.0 min.

Conclusion: Analysis of the results showed evidence of a learning curve with improvement of time with an increasing number of patients. The method provides a safe and inexpensive solution for catheterization of the coronary sinus, easily accessible to every catheter laboratory.
Increased ventricular sialylation in patients with heart failure secondary to ischemic heart disease
Authors: Robert Crook J. , Goldman Jonathan H. , Madden Brendan , Mckenna William J. , Dalziel Martin
Published: February 2009

Background: Elevated serum sialic acids are associated with increased cardiovascular mortality, but sialic acid levels have not been studied in cardiac tissue.

Methods: Myocardial samples were obtained at the time of transplantation from 23 patients (age 54 ± 12 years) with heart failure secondary to ischemic heart disease and 16 patients (age 51 ± 7 years) with idiopathic dilated cardiomyopathy (DCM). A control group comprised postmortem samples obtained from 14 patients (age 70 ± 5 years) who died of non‐cardiovascular causes. Ventricular sialylation was quantitated using the sialic acid‐specific lectins Maackia amurensis agglutinin (MAA) and Sambucus nigra agglutinin (SNA) using a chemiluminescence assay. Results are expressed as the percentage (± standard error of the mean) of the binding of lectin to a standardized control sample of human myocardium.

Results: Ventricular sialylation recognized by MAA was 55 ± 7% in patients with heart failure secondary to ischemic heart disease compared with 26 ± 7% for DCM (p = 0.006) and 32 ±8% for controls (p = 0.04), and that recognized by SNA was 69 ± 7% in patients with heart failure secondary to ischemic heart disease compared with 42 ± 6% for DCM (p = 0.006) and 38 ± 7% for controls (p = 0.006). No significant difference in ventricular sialylation was observed between patients with DCM and controls.

Conclusion: Myocardial levels of sialic acids are significantly increased in patients with heart failure secondary to ischemic heart disease compared with patients with idiopathic dilated cardiomyopathy and controls. Our findings are important in view of recent reports of an association between serum sialic acid concentration and cardiovascular mortality and require further investigation.
Immediate and chronic results of cutting balloon angioplasty: A matched comparison with conventional angioplasty
Authors: Kondo Taizo , Kawaguchi Katsuhiro , Awaji Yoshifumi , Mochizuki Mitsuhiro
Published: February 2009

Background: At the initial stages of percutaneous transluminal coronary angioplasty (PTCA), several studies reported on the feasibility of coronary artery incision and dilatation leading to the extension of the PTCA technique.

Hypothesis: This study was designed to determine the immediate and chronic results of cutting balloon (CB) angioplasty.

Methods: This procedure was performed on 127 lesions in 110 patients (male 83%, age 61.8 ± 9.3 years).

Results: The overall procedural success rates for the CB were 93.7% (119 lesions) and 92.7% (102 patients), while solitary CB without pre‐ and/or postdilatation was 76.4% (91 lesions). There was one major in‐hospital complication (Q‐wave myocardial infarction, 0.9%), but there were no deaths or emergency coronary artery bypass graftings. Significant angiographic dissections (≥ grade C) occurred in four patients, and coronary perforation occurred in one. The successfully treated CB group (95 lesions) was matched with the successful conventional angioplasty group (PTCA group) for chronic result assessment in regard to reference vessel size and lesion characteristics. In the CB group, postprocedural minimal luminal diameters were significantly larger and the percentage of stenosis at the stenotic site was significantly lower compared with the PTCA group. Restenosis occurred in 22 lesions (23.1%). This showed a significantly lower restenosis rate compared with the PTCA group (42.1%). In addition, the restenosis rate of the CB without inclusion of the pre‐ and/or postdilatation‐treated lesions was 19.7%.

Conclusions: (1) Cutting balloon angioplasty procedures can be performed with high success rates with few major in‐hospital events. (2) The restenosis rate in the CB group was significantly lower compared with the PTCA group.