bluuebunny/crossref_metadata_2025 huggingface dataset:
Conservative treatment for brucella endocarditis
Authors: Cohen Natan , Golik Ahuva , Alon Irena , Zaidenstein Ronit , Dishi Victor , Modai David , Karpuch Julio , Zyssman Itzchak
Published: February 2009

Endocarditis is the most devastating complication of brucellosis. The accepted treatment for Brucella endocarditis (BE) is a combination of valve replacement and antibiotics. Conservative antibiotic treatment alone is not recommended by most authors, as it is considered ineffective, risking fatality. We describe a patient with BE, in whom antibiotic treatment alone resulted in complete recovery. On reviewing the literature, we found 12 additional such cases. We compared this group of 13 patients with data from 49 published cases treated with a combination of surgery and antibiotics, with afavorable outcome. Absence of congestive heart failure or a prosthetic valve, relatively mild extravalvular cardiac involvement, and a somewhat shorter disease history until initiation of treatment were characteristic of the group treated conservatively in comparison with patients who underwent surgery. In selected patients with BE, conservative antibiotic treatment may be a valid alternative to surgery.
Bronchiolitis obliterans organizing pneumonia during low‐dose amiodarone therapy
Authors: Jessurun Gillian A.J. , Crijns Harry J.G.M. , Hoogenberg Klaas
Published: February 2009

Two cases of amiodarone‐induced pulmonary toxicity during a relatively short period of low‐dose amiodarone treatment are reported. The toxicity risk of amiodarone is determined by cumulative factors in individual patients.
Percutaneous balloon catheter closure of a patent foramen ovale in a patient with pulmonary disease, profound hypoxemia, and normal right heart pressures
Authors: Allan John J. , Marinelli Carlos , Dellsperger Kevin C. , Winniford Michael D.
Published: February 2009

Right‐to‐left intracardiac shunting across a patent foramen ovale (PFO) has been reported in patients with pulmonary embolism, right ventricular (RV) infarction, positive pressure ventilation with positive end‐expiratory pressure, heart failure with left ventricular assist devices, cardiac tamponade, and unilateral diaphragmatic paralysis. The primary driving force for these shunts is a reduction in the compliance of the pulmonary bed or right ventricle; right atrial pressure is usually elevated and pulmonary hypertension is frequently present. Significant shunting and hypoxemia are unusual in the absence of these diseases. We encountered a patient with normal pulmonary pressures, severe hypoxemia, pulmonary disease, and intracardiac shunting across a PFO in whom it was difficult to determine how great a role intracardiac shunting was playing in his hypoxemia. To assess this, we performed percutaneous balloon catheter occlusion of the PFO, using transthoracic echocardiography with contrast to confirm closure of the PFO. Therapeutic balloon occlusion has been reported in severe hypoxemia due to shunting across a PFO in a patient with RV infarction. Our case is unique, however, in two respects. First, this patient had normal right‐sided cardiac pressures and normal RV function and, thus, no obvious driving force for a significant right‐to‐left shunt. Second, transthoracic echocardiography with contrast was used before and after balloon inflation to confirm closure of the PFO. This technique helped to answer the important clinical question of whether surgical closure of the PFO in this patient with both lung disease and intracardiac shunting would significantly improve his oxygenation.
The design of the mortality assessment in congestive heart failure trial (MACH‐1, Mibefradil)
Authors: Barry Levine T.
Published: February 2009

Background: Despite the advances in therapy for heart failure with the use of angiotensin‐converting enzyme inhibitors, heart failure remains a major medical problem, impacting on well‐being and survival.

Hypothesis: Mibefradil is a member of new class of agents that, due to its unique mechanism of action and pharmacologic and physiologic profile, may offer a significant advance in the treatment of heart failure. Mibefradil is a nonvoltage‐regulated T‐channel calcium blocker that differs from all the other currently available L‐channel calcium blockers. The drug is a potent peripheral and coronary vasodilator, with no clinical negative inotropic activity. Furthermore, because of its long half‐life, it can be given once a day and appears to be free of the common side effects seen with other calcium‐channel blockers. The trial was designed to investigate whether the addition of mibefradil to standard therapy for heart failure will reduce mortality in patients with symptomatic heart failure.

Methods: This manuscript describes the design, organization, and status of MACH‐1 (Mortality Assessment in Congestive Heart Failure), a double‐blind, placebo‐controlled study. It is to be a 2,400‐patient international trial assessing the ability of mibefradil to impact upon survival and symptoms of heart failure in patients who are in NYHA classes II–IV and who were already treated with standard therapy.
Usefulness of laboratory mental stress test in patients with stable coronary artery disease
Authors: Wong Cheuk‐Kit , Ben Freedman S.
Published: February 2009

Background and hypothesis: Many episodes of ischemia in daily life are silent occurring during sedentary activities and may be related to mental stress. In 35 patients with stable angina and positive exercise test awaiting bypass surgery, we investigated whether laboratory mental stress tests would trigger ischemia of a comparable severity to that occurring in daily life and attempted to elucidate some of the underlying mechanisms.

Methods: All patients underwent exercise testing, personality assessment, 2‐day Holter monitoring, and laboratory mental stress tests while on their usual medications.

Results: Only four patients (12%) had positive mental stress test (ST depression ≥0.1 mV). All episodes were silent and usually associated with fast heart rate (>90 beats/min). In contrast, ambulatory ischemia was common (average duration of 51 min per 24 h), and at least one episode was recorded in 27 patients (77%) including the 4 with positive test. Patients with positive mental stress test had a higher heart rate during testing (124 ± 24 vs. 86 ± 16 beats/min, p<0.01), and a shorter exercise time and time to 1 mm ST depression on cycle ergometry than those with negative mental stress test. None of the four patients were on beta blockers. There was no difference in personality inventory between the two groups. Comparisons between patients with and without positive mental stress test revealed no difference in the duration and frequency of ambulatory ischemia, or in the occurrence of silent ischemia. However, the heart rate at onset of ambulatory ischemia tended to be higher in the patients with positive mental stress test (96 ± 9 vs. 62 ± 43, p = 0.07). Further subgroup analysis in patients without beta blockers (4 mental stress test positive and 18 negative) showed similar results.

Conclusions: Laboratory mental stress test is a weak inducer of ischemia detected by electrocardiographic monitoring in patients with frequent ambulatory ischemia. Wall motion evaluation during mental stress test may improve sensitivity. While larger scale studies may determine its clinical role, the present study illustrated that patients with heightened heart rate response to mental stress were identified in whom beta blockers could be the drug of choice.
Coronary artery stenting with high‐pressure post‐dilation followed by adjunctive thrombolysis after failed coronary angioplasty for acute myocardial infarction: Report of three cases
Authors: Iwasaki Kohichiro , Yamasaki Satoshi , Takeuchi Kazuteru , Matono Sigeru , Kita Toshimasa , Kusachi Shozo
Published: February 2009

We successfully implanted coronary stents into refractory reoccluded lesions after failed coronary angioplasty in three patients with acute myocardial infarction (AMI). Lesion location was the proximal left anterior descending coronary artery in two patients and the dominant right coronary artery in one patient. The reference diameters of the lesions were 3.64, 3.33, and 3.50 mm, respectively. A stent with a luminal diameter of 3.0 mm was implanted in all patients. Poststenting dilation of the stent was performed at high pressure (18 atm), and urokinase was administered immediately thereafter. Heparin was administered for 24 h with maintenance of activated coagulation time within 180–200 s. Warfarin was then administered to keep the international normalized ratio within 2.5–3.5. Luminal diameters immediately after stenting were 3.14, 2.89, and 3.26 mm, and those at 1 month after stenting were 3.09, 2.81, and 3.12 mm, respectively, indicating good patency. Our experience in these cases suggests that coronary stenting can be applied after unsuccessful coronary angioplasty in selected patients with AMI. The present report includes informative reference data on diameter, postdilation, adjunctive thrombolytic agent administration, and adequate anticoagulation therapy in coronary stenting in this acute application.
Severe ventricular dysfunction secondary to subarachnoid hemorrhage
Authors: Soman P. , Senior R.
Published: February 2009

A 39‐year‐old man was brought to the emergency department in a coma. The electrocardiogram showed partial left bundle‐branch block and ST elevation in precordial leads, and serum creatinine kinase activity was elevated. Two‐dimensional echocardiography revealed severe biventricular dysfunction. Autopsy demonstrated the presence of subarachnoid hemorrhage. Coronary arteries and the myocardium were macroscopically normal.
“Tombstone” anterior st‐segment elevations secondary to acute pericarditis: the role of two‐dimensional echocardiogram
Authors: Jain Avanindra
Published: February 2009

Prompt and appropriate administration of thrombolytic therapy is important for patients with acute myocardial infarction. However, in addition to contraindications, alternative causes of ST‐segment elevation should be considered before thrombolytic therapy is instituted. A patient with marked ST‐segment elevation in the anterior leads suggestive of acute ischemia is presented. Because of lack of ischemic symptoms, an echocardiogram was performed. This showed mild generalized hypokinesis, and thrombolytic therapy was not administered. Subsequent ECGs demonstrated evolutionary findings consistent with pericarditis. In selected patients a two‐dimensional echocardiogram, which can be easily performed at patient bedside, will help in appropriate patient management.
Incomplete bundle‐branch block and st‐segment elevation: Syndrome associated with sustained monomorphic ventricular tachycardia in patients with apparently normal heart
Authors: Brembilla‐Perrot BÁAtrice , Beurrier Daniel , Jacquemin Laurent , Kubler Luc , Brouant BenoÎOt , Demoulin StÁPhane , Lucron Hugues , Danchin Nicolas
Published: February 2009

This paper reports on three cases of patients with an apparently normal heart admitted for sustained monomorphic ventricular tachycardia. The only abnormal finding showed in the electrocardiogram (ECG) in sinus rhythm that exhibited an entity associated with incomplete right bundle‐branch block and persistent ST‐segment elevation. The ECG entity was variable and disappeared transiently. Spontaneous ventricular tachycardia in one patient was inducible by programmed stimulation. There was no underlying heart disease. The origin of the ventricular tachycardia in one patient was located by pace mapping in the left ventricle at the left ventricular basal septum. The follow‐up (from 6 months up to 6 years) demonstrated a good prognosis. This particular ECG entity associated with monomorphic ventricular tachycardia could have been missed because of the variations in the ECG in sinus rhythm and was associated with a favorable prognosis.
Observer bias in the interpretation of dobutamine stress echocardiography
Authors: Tighe John F. , Steiman David M. , Vernalis Marina N. , Taylor Allen J.
Published: February 2009

Background and hypothesis: Blinded image analysis is typically utilized in published studies evaluating the accuracy of dobutamine stress echocardiography (DSE). However, in clinical settings, practical considerations may limit the use of blinded interpretations and thus the potential for observer bias arises. This study evaluated the relationships between clinical and blinded interpretations of DSE.

Methods: Wall motion analysis from clinical and blinded DSE interpretations were compared and factors associated with their concordance were investigated in 115 consecutive patients with known or suspected coronary artery disease.

Results: Clinical and blinded interpretations agreed on the presence or absence of inducible ischemia in 102 of 115 cases (88.7% k = 0.76, p<0.00001). In studies in which the clinical and blinded interpretations were in agreement, there was greater ST‐segment depression (STD) in echocardiographically positive compared with negative studies (mean STD 0.73 ± 0.65 vs. 0.42 ± 0.67 mm; p = 0.008). In contrast, studies in which there was disagreement had significantly less ST‐segment changes (mean STD 0.19 ± 0.56 mm; p = 0.012) despite comparable results on blinded wall motion analysis. Multiple logistic regression for factors related to the results of clinical and blinded wall motion analysis disclosed that angina pectoris and ST‐segment changes were related to clinical interpretations, whereas only angina pectoris was related to the findings on blinded analysis.

Conclusions: Clinical interpretations of echocardiographic images during DSE overall demonstrate good agreement with the results of blinded analysis. Ancillary testing data may influence the analysis of wall motion abnormalities, and thus the potential for observer bias exists unless these interpretations are performed blinded to other clinical data.
The role of “Ischemic ST‐segment Counterpoise” in rendering the response of exercise electrocardiogram falsely negative
Authors: Madias John E. , Khan Mujtaba , Manyam Bose
Published: February 2009

Exercise electrocardiogram (ECG) has a high rate of false negative results in comparison with simultaneously performed thallium‐201 perfusion scintigraphy, particularly in patients with single‐vessel coronary artery disease, low exercise workload, inadequate heart rate rise, and resting ECG abnormalities. We present the case of a patient in whom thallium‐201 SPECT scintigram revealed equally extensive and severe myocardial ischemia in two myocardial planes opposite each other. The accompanying exercise ECG did not disclose ischemic changes despite the adequacy of heart rate rise in this patient with severe right and left anterior descending coronary artery disease. We propose, as an explanation for this phenomenon, that in this patient the ischemic ST‐segment vectors of equal magnitude and direction but of opposite sense, generated during stress, cancelled each other (“ischemic ST‐segment counterpoise”), thus rendering the exercise ECG normal.
Nonsecretory immunoglobulin‐derived amyloidosis of the heart: Diagnosis by immunohistochemistry of the endomyocardium
Authors: Chau Elaine M.C. , Cheung Stephen C. W. , Chow Simon L. , Fu Kin‐Hang
Published: February 2009

Primary amyloid light chain (AL) amyloidosis of the heart is a rare cause of congestive heart failure. Approximately 15% of patients with primary AL amyloidosis demonstrate no monoclonal proteins on serum or urine immunoelectrophoresis (so‐called nonsecretory immunoglobulin‐derived amyloidosis). The histologic findings of endomyocardial biopsy from these patients may be indistinguishable from those with senile cardiac amyloidosis. However, the AL type may respond favorably to chemotherapy while the latter type does not. The prognosis is also better in the senile cardiac amyloid type. The precise diagnosis in the present case was made by applying immunohistochemical techniques on cardiac tissues.
Non‐hodgkin's lymphoma of the heart in patients infected with human immunodeficiency virus
Authors: Duong Michel , Dubois Claudine , Buisson Marielle , Grappin Michelle , Chavanet Pascal , Portier Henri , Eicher Jean Christophe
Published: February 2009

A case of HIV‐associated cardiac non‐Hodgkin's lymphoma (NHL) is described, and the epidemiologic and clinicopathologic features of 21 cases previously reported in the literature are analyzed. All patients were homosexual males, and the cardiac NHL was the first acquired immune deficiency syndrome‐defining condition in the majority. Patients were referred with nonspecific clinical findings including dyspnea and tachycardia, but rapid progression of cardiac dysfunction was frequent after symptoms appeared. Echocardiography constitutes the most useful noninvasive procedure in the diagnosis of cardiac NHL. Most of the patients had disseminated disease at initial presentation; pathologically, the lymphomas were of B lymphocyte origin and of high‐grade subtypes. Prognosis of HIV‐associated cardiac NHL is generally poor, although clinical remission has been observed with combination chemotherapy. Cardiac lymphomas in HIV‐associated patients are typically high‐grade and often disseminate early. Although the prognosis is poor, patients in whom dissemination has not occurred could have longer survival under systemic chemotherapy.
The “open artery hypothesis” in survivors of myocardial infarction
Authors: Pitts William R. , Cigarroa Joaquin E. , Lange Richard A. , David Hillis L.
Published: February 2009

In survivors of acute myocardial infarction, the restoration of antegrade flow in the infarct‐related coronary artery may improve prognosis by a mechanism independent of its effect on left ventricular function. Survival may be enhanced even when restoration of flow is accomplished days or weeks after the acute event. In a series of retrospective studies of survivors of a first myocardial infarction, it was shown that long‐term survival is significantly better in those with than in those without antegrade flow in the infarct‐related artery. It is hypothesized that late restoration of antegrade flow in the infarct‐related artery renders the border zone of the infarction more electrically stable, thereby diminishing the incidence of ventricular tachyarrhythmias and sudden death.
Imaging techniques for coronary artery disease: Current status and future directions
Authors: Noel Merz C. Bairey , Berman Daniel S.
Published: February 2009

We review the current status and future directions of sestamibi single‐photon emission‐computed tomography (SPECT), positron emission tomography (PET), magnetic resonance imaging (MRI), and contrast perfusion echocardiography (CPE) for coronary artery disease evaluation. Diagnostic accuracy and adjunctive assessment of ventricular function make sestamibi SPECT the currently favored stress imaging radioisotope technique. Tissue attenuation correction will likely enhance these capabilities of SPECT in the near future. PET potentially offers valuable diagnostic information, as it may be a superior technique where body habitus limits cardiac imaging. We project that it is unlikely to become routinely used for cardiac imaging because of improvements in routine radionuclide imaging and the lack of evidence that the small resolution gain with PET is of importance, given the much larger cost. Cardiac MRI for assessing cardiac function, perfusion, and coronary angiography is an exciting new modality at an early stage of development. The possible comprehensive nature of MRI for coronary artery disease evaluation, potential cost savings related to utilization of a single, noninvasive test, and availability of scanning equipment in current community settings all project an important role for MRI in the future. Contrast perfusion echocardiography is also a relatively new and untested imaging modality which offers great future promise. The recent development of intravenous contrast agents and the current widespread availability of echocardiographic expertise and equipment throughout the country suggest that the speed of development as well as the dispersion of technologic advances will be rapid. We project that these techniques will play important roles in future coronary artery disease testing and will result in improved diagnostic efficacy and possibly cost utility.
Use of cardiac troponin t rapid assay in the diagnosis of a myocardial injury secondary to electrical cardioversion
Authors: Garré Luis , Álvarez Ángel , Rubio Mariá , Pellegrini Alejandro , Caridi Mariá , Berardi Alfredo , Lázzaro Carmen , Blanco Patricia , Menehem Claudia , Díaz MóNica
Published: February 2009

Background and hypothesis: This study was carried out to determine whether cardiac troponin T test in rapid assay gives positive results in patients previously submitted to cardioversion or electrical defibrillation.
Methods: Forty patients with supraventricular tachyarrhythmias lasting no more than 2 days were treated with electrical cardioversion. The total creatine phosphokinase (CPK)‐MB isoenzyme and troponin T in rapid assay were measured at baseline and at 6, 12, and 24 h thereafter.
Results: Total CPK baseline levels were normal in all cases; within 4 h, the serum CPK levels increased by 98%, at 6 h by 111.5%, at 12h by 168%, and at 24 h by 225% (p<0.01). The CPK‐MB isoenzyme showed no percentage increase of total CPK higher than 5%, measured at 6, 12, and 24h after the shock, independent of the number of attempts of cardioversion. The troponin T test was also negative in all cases at baseline and at 6, 12, and 24 h after cardioversion.
Conclusion: We conclude that the absence of elevations in CPK‐MB levels and cardiac troponin T levels matched clinical and electrocardiographic results showing absence of myocardial damage after electrical cardioversion.
The prognostic significance of angina pectoris experienced during the first month following acute myocardial infarction
Authors: Jespersen Christian M.
Published: February 2009

Background: Angina pectoris accompanied by transient ST‐segment changes during the in‐hospital phase of acute myocardial infarction (AMI) is a well established marker of subsequent cardiac death and reinfarction.

Hypothesis: This study was undertaken to record the prognostic significance of angina pectoris experienced during the first month following discharge from AMI.

Methods: In all, 803 patients included in the placebo arm of the Danish Verapamil Infarction Trial II were followed up for 18 months in 20 coronary care units in Denmark. The patients were randomized to placebo and were still on study treatment 1 month after discharge. Of these patients, 311 (39%) reported chest pain during the first month following discharge.

Results: Patients with angina pectoris had a significantly increased risk of reinfarction [hazard 1.71; 95%‐confidence limit (CL): 1.09, 2.69] and increased mortality risk which, however, only reached borderline statistical significance (hazard 1.52; 95%‐CL: 0.96, 2.40). When patients were subdivided according to both angina pectoris and heart failure, those with one or both of these risk markers had significantly increased mortality (p 0.03) and reinfarction (p 0.02) rates compared with patients free of both angina pectoris and heart failure.

Conclusion: Patients with postinfarction angina pectoris have a significantly increased morbidity risk.
The benefit of low‐dose dopamine during vigorous diuresis for congestive heart failure associated with renal insufficiency: Does it protect renal function?
Authors: Varriale Philip , Mossavi Ahmad
Published: February 2009

Background: Low‐dose dopamine, a renal vasodilator, has been used empirically to improve renal function or outcome in critically ill patients with oliguria or acute renal failure.

Hypothesis: This study was designed to investigate the efficacy of low‐dose dopamine (2 μg/kg/min) as a renal‐protective agent during vigorous diuresis for congestive heart failure (CHF) associated with mild or moderate renal insufficiency.

Methods: Of 20 study patients (mean age 74.3 ± 15 years) with severe CHF, 10 (Group A) were randomized to a treatment strategy of intravenous bumetanide (1 mg b.i.d.) alone and another 10 (Group B) to low‐dose dopamine and a similar diuretic regimen for a duration of 5 days or less if clinical edema remitted.

Results: Group B patients showed a significant improvement in renal function and urinary output: serum blood urea nitrogen 48.9 ± 10.3 to 32.1 ± 14.4 mg/dl (p<0.05); serum creatinine 1.97 ± 0.24 to 1.49 ± 0.39 mg/dl (p“0.05); creatinine clearance 35.6 ± 11.6 to 48.8 ± 12.3 ml/min (p“0.05); and indexed urinary output 0.56±0.16 to 2.02±0.72 ml/kg/h (p“0.05). Group A patients showed a significant increase in urinary output but nonsignificant renal functional deterioration.

Conclusion: The renal‐protective effect of low‐dose dopamine in the setting of CHF and vigorous diuresis is supported by this study.
Post‐traumatic ventricular septal defect following coronary bypass surgery
Authors: Bortolotti Uberto , Milano Aldo , Scioti Giovanni , Tartarini Giuseppe
Published: February 2009

A 60‐year‐old patient underwent triple coronary artery bypass grafting following an inferoseptal myocardial infarction and early onset of exertional angina. Four years later he was involved in a car accident during which he sustained an abdominal and thoracic trauma. Approximately 1 month after discharge, a ventricular septal defect was diagnosed by two‐dimensional Doppler echocardiography with patency of all grafts at coronary angiography. Closure of the septal defect was successfully accomplished through a right atrial approach. Rupture of the ventricular septum following blunt chest trauma in a patient with previous myocardial revascularization has not been previously reported.
Dofetilide in patients with left ventricular dysfunction and either heart failure or acute myocardial infarction: Rationale, design, and patient characteristics of the DIAMOND studies
Authors: Mosller M
Published: February 2009

Background: Attempts to prolong life with antiarrhythmic drugs in patients at increased risk of sudden cardiac death have so far been disappointing or inconclusive.

Hypothesis: The Danish Investigations of Arrhythmia and Mortality ON Dofetilide (DIAMOND) encompass two survival studies testing the prophylactic use of the selective potassium‐channel blocker, dofetilide, in patients at high risk of sudden death.

Methods: The first study includes patients admitted to hospital with congestive heart failure (CHF), the other includes patients with acute myocardial infarction (MI) within the previous 7 days. In both studies patients must have left ventricular systolic dysfunction (ejection fraction 35%) determined by echocardiography. Each of the two studies are planned to enroll 1500 patients. Consecutive hospitalized patients with MI or CHF are screened in 37 Danish hospitals. Eligible patients are randomized to receive dofetilide or matching placebo. All patients are continuously monitored by telemetry for the first 3 days of the study to detect possible arrhythmic events and to ensure resuscitation in case of serious arrhythmias. Minimum duration of follow‐up is 12 months.

Results: Between November 1993 and July 1996, a total of 5812 consecutive patients with CHF and 8688 consecutive patients with MI was screened for entry. Of these, 1518 patients were included in the CHF study and 1510 patients in the MI study. Overall 1‐year mortality of randomized patients were 28 and 22%, respectively.

Conclusion: DIAMOND will provide important data on the safety and efficacy of dofetilide in high‐risk patients with left ventricular dysfunction and either CHF or MI, as well as evaluate tolerability in these populations.
Early and long‐term outcome of aortic valve replacement with homograft versus mechanical prosthesis—8‐year follow‐up study
Authors: Waszyrowski Tomasz , Kasprzak JarosłAW D. , Ńska‐Pakuła Maria Krzemi , Dziatkowiak Antoni , ZasLonka Janusz
Published: February 2009

Background: Aortic valve disease is an important and frequent clinical problem with a mortality rate as high as 50–80% in a 5‐year natural history of patients with severe aortic valve disease. Biological or mechanical prosthesis implantation is the only way to improve prognosis.

Hypothesis: The aim of our study was to assess the clinical outcome of aortic valve replacement according to the underlying valve pathology and the type of replacement device, that is, aortic homografts versus mechanical prostheses.

Methods: The study group consisted of 143 patients with a mean follow‐up period of 4.1 ± 2.7 years. All patients had annual clinical and Doppler echocardiographic evaluation.

Results: Total 8‐year mortality was 4.9% (7/143) including early mortality of 1.4%. Eight‐year survival probability was not significantly higher in the homograft than in the mechanical prosthesis recipients. No differences were found among subgroups with aortic stenosis, insufficiency, and combined disease. Overall early and late complication rate (13.3 and 24.8%, respectively) was similar in homograft and mechanical valve recipients. The most common late complications were ventricular arrhythmia (10%) (Lown class I–III), pre‐dominantly in the homograft recipients (17.7 vs. 3.7%), and heart failure (9.2%), more frequent in mechanical valve recipients (14.8 vs. 1.6%). Thromboembolic events occurred in 6.3%, infective endocarditis in 4.2% (more common in mechanical valve recipients), serious bleeding in 3.7% (only in mechanical valve recipients). There was no significant difference in early and late complication rate among subgroups (aortic stenosis, insufficiency, and combined disease). Of the patients studied, 91.6% improved in functional status after surgery, with significantly better outcome in homograft recipients. The type of preexisting valve disease did not influence clinical improvement.

Conclusion: Early and late mortality as well as estimated probability of survival and hemodynamic improvement at 8‐year follow‐up after aortic valve replacement are independent of the type of implanted valve. Complication rate does not depend upon the type of preexisting valve pathology, but severe late complications are more common after mechanical valve implantation than after homograft implantation.
Molecular evaluation of enteroviruses in the pathogenesis of idiopathic dilated cardiomyopathy
Authors: Jeffery S. , Kelling P. J. , Lukaszyk A. , Mckenna W. J. , Boriskin Y. S. , Booth J. C. , Hodgson J. , Davies M. J.
Published: February 2009

Background: There is great disparity in the literature as to the presence and relevance of enterovirus in heart tissue from patients with dilated cardiomyopathy (DCM). Published estimates of enteroviral positive tissue in DCM range from 0 to 50%. Very little sequence information is so far available on those samples which are positive.

Hypothesis: Re‐examination of fresh biopsy material from patients previously tested, plus 13 new cases of DCM, and sequencing the products would yield information on the validity of the technique and on the type of virus being detected.

Methods: RNA from biopsy or explant tissue was tested for the presence of enterovirus using reverse transcriptase polymerase chain reaction (PCR). The nucleotide sequences of all positive PCR products were determined by direct sequencing.

Results: Positive PCR signals were found in 10% of samples from patients with DCM and in 16% of control tissues. Two DCM and 12 control samples gave the same nucleotide sequence, which was different from the CB3 used as a positive control. The other 4 DCM samples all produced multiple bands on sequencing.

Conclusion: The results do not support a major role for enterovirus in DCM. There is need for some caution, however, as a review of the literature shows that studies using single biopsies, such as this one, produce consistently lower estimates for enterovirus than do those wherein multiple biopsies are examined.
Biochemical characterization of myocardial damage in chronic chagas' disease
Authors: Carrasco G. Hugo A. , Olmos Leopoldo , Dipaolo Alberto , Alarcon Marino , Burguera José , Burguera, Marcela , Carrasco V. Hugo R.
Published: February 2009

Background: In the early asymptomatic stages of cardiomyopathy in chronic Chagas' disease, septal endomyocardial biopsies disclose multiple evidence of evolving myocardial damage. Detection of signs of an active myocardiopathic process may allow a better understanding of the evolution of this and other related dilated cardiomyopathies and provide a means for evaluation of the result of future therapeutic schemes.

Hypothesis: This study was designed to explore whether cellular damage caused by Chagas' disease is reflected by changes of certain serum electrolytes, enzymes, and glycoproteins associated with myocardial metabolism, especially in the coronary sinus into which the blood just metabolized by the heart is drained.

Methods: The study included 47 patients (35 men and 12 women, average age 40 years) with positive complement fixation reaction and hemagglutination test for Chagas' disease. The study protocol included medical records, electrocardiographic (ECG) recordings, routine laboratory analysis, chest x‐rays, noninvasive cardiac examinations, and cardiac catheterization.

Results: In this study, we determined the concentration or activity of 9 electrolytes, 5 glycoprotein fractions, and 12 enzymes related to cardiac metabolism in blood from the coronary sinus, the superior vena cava, the pulmonary and femoral arteries, and found early release of inorganic phosphorus (p<0.01) and isocitrate dehydrogenase (p<0.01) from the heart and increased activity of serum alkaline phosphatase and aldolase (p<0.05). Discriminant analysis suggested that the combination of the clinical picture, electrocardiographic findings, and peripheral activity of serum aldolase might be useful for the recognition of 86% of patients with Chagas' disease without segmental myocardial damage, 80% of those with early segmental abnormalities, and all patients with advanced myocardial damage or congestive heart failure.

Conclusion: These results would make the application of more invasive techniques, such as left cineventriculography for detection of early myocardial compromise, unnecessary.
Polymorphism in apolipoprotein(a) kringle IV 37 (Met/Thr): Frequency in a London population and its association with coronary artery disease
Authors: Syrris Petros , Jeffery Steve , Carter Nick , Schwartzman Raul , Kaski Juan Carlos
Published: February 2009

Background: A raised concentration of lipoprotein(a) [Lp(a)] in human plasma has been considered as a risk factor for coronary artery disease (CAD). Apolipoprotein(a) and plasminogen genes are exceptionally similar to a variable number of plasminogen‐like kringle IV repeats in the apo(a) gene. Polymorphisms have been previously identified in the apolipoprotein(a) kringle IV 37.

Hypothesis: In order to determine the frequency of the apolipoprotein(a) kringle IV 37 Met66→Thr polymorphism in a London‐based population and to assess the relationship of this polymorphism with CAD in Caucasian patients, we geno‐typed two groups of people of different ethnic origin (Caucasian and Afro‐Caribbean) for the mutation using standard polymerase chain reaction (PCR) techniques.

Methods: The first group consisted of 182 unrelated Caucasian patients (107 men and 75 women, mean age 59.7 ± 10.2 years) recruited at St. George's Hospital. They were defined as patients with 0, 1 or ≥ 2 vessel disease patients depending on the degree of stenosis in none, one, or several major epicardial arteries. The second group comprised 64 unrelated patients of Afro‐Caribbean origin attending a hypertension clinic at St. George's Hospital.

Results: It was shown that the prevalence of the Met66→Thr mutation is markedly higher in Caucasians than in Afro‐Caribbeans and that this mutation is not associated with either Lp(a) levels or severity of CAD.
Nonneoplastic diseases of aorta and pulmonary trunk—Part III
Authors: Waller Bruce F. , Clary James D. , Rohr Todd
Published: February 2009

This five‐part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more diseases affect the aorta compared with the pulmonary trunk and right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part III of this five‐part series discusses the etiology of aortic aneurysms and aortitis.
Coronary embolism complicating aortic valve endocarditis: Treatment with placement of an intracoronary stent
Authors: Glazier James J. , Mcginnity John G. , Spears J. Richard
Published: February 2009

A 37‐year‐old man, who had received 3 weeks of antimicrobial therapy for aortic valve endocarditis, presented with an acute anteroseptal wall myocardial infarction. Coronary angiography demonstrated occlusion of the mid left anterior descending artery, thought to have been caused by embolization of a sterile vegetation. Following failure of balloon dilation to achieve vessel patency, this was achieved by placement of an intracoronary stent.
Coronary artery vasomotion after percutaneous transluminal coronary angioplasty
Authors: Misra Vijay K. , Agirbasli Mehmet , Fischell Tim A.
Published: February 2009

Substantial evidence of postangioplasty vasoconstriction is available, both at the dilated site and distal to balloon injury, demonstrating its frequent occurrence. It is likely that even mild or moderate vasoconstriction at the site of balloon injury may create flow turbulence, promoting platelet aggregation and contributing to thrombotic vessel closure. The regulation of arterial smooth muscle tone is a complex process and should be distinguished from elastic recoil, which occurs at the site of balloon injury due to passive elastic properties of the artery, generally immediately after balloon deflation. The contribution of a variety of messengers generated by humoral, neurogenic, myogenic, and endothelium‐derived factors in this regulatory process has been implicated. The possible mechanisms of post‐percutaneous transluminal coronary angioplasty vasoconstriction at the dilated site (local) and in segments of coronary artery beyond the dilated site (distal) are reviewed in this article.
Doppler echocardiography distinguishes between physiologic and pathologic “silent” mitral regurgitation in patients with rheumatic fever
Authors: Minich L. Luann , Tani Lloyd Y. , Pagotto Luciana T. , Shaddy Robert E. , Veasy L. George
Published: February 2009

Background: The diagnosis of rheumatic fever is based on physical findings (major) and supporting laboratory evidence (minor) as defined by the Jones criteria. Rheumatic carditis is characterized by auscultation of a mitral regurgitant murmur. Doppler echocardiography, however, may detect mitral regurgitation when there is no murmur (“silent” mitral regurgitation), even in normal individuals.

Hypothesis: The hypothesis of this study was that physiologic mitral regurgitation can be differentiated from pathologic “silent” mitral regurgitation by Doppler echocardiography.

Methods: The study group consisted of 68 patients (2–27 years) with normal two‐dimensional imaging and Doppler evidence of mitral regurgitation but no murmur. Patients with rheumatic fever (n = 37) met Jones criteria (chorea in 20, arthritis in 17). Patients without rheumatic fever (n = 31) were referred for innocent murmur (n = 7), abnormal electrocardiogram (n = 13), and chest pain (n = 11). Echoes were independently reviewed by two cardiologists blinded to the diagnosis. Pathologic mitral regurgitation was defined as meeting the following four criteria: (1) length of color jet > 1 cm, (2) color jet identified in at least two planes, (3) mosaic color jet, and (4) persistence of the jet throughout systole. Jet orientation was also noted.

Results: Using the above criteria, there was agreement in echo interpretation of pathologic versus physiologic mitral regurgitation in 67 of 68 patients (interobserver variability of 1.5%). Pathologic regurgitation was found in 25 (68%) patients with rheumatic fever but in only 2 (6.5%) patients without rheumatic fever (p<0.001). The specificity of Doppler for detecting pathologic regurgitation was 94% with a positive predictive value of 93%. The color mitral regurgitant jet was posteriorly directed in all 25 patients with rheumatic fever.

Conclusion: Pathologic “silent” mitral regurgitation of rheumatic fever can be distinguished from physiologic mitral regurgitation using strict Doppler criteria, particularly when the jet is directed posteriorly. These data support the use of Doppler echocardiography as a minor criterion for evaluating patients with suspected rheumatic fever.
Sensitivity and specificity of left ventricular ejection fraction by echocardiographic automated border detection: Comparison with radionuclide ventriculography
Authors: Lucariello Richard J. , Sun Ying , Doganay Guldene , Chiaramida Salvatore A.
Published: February 2009

Background: Echocardiographic automated border detection (ABD) provides on‐line, beat‐to‐beat estimation of left ventricular (LV) ejection fraction (EF). Sensitivity and specificity of using ABD‐EF for diagnosing LV dysfunction in routine clinical situations have not been previously studied.

Hypothesis: Analysis of ABD‐EF data based on receiver operating characteristic (ROC) should provide useful information about sensitivity and specificity for clinical diagnosis of LV function based on ABD‐EF.

Methods: The study group included 50 consecutive patients with EF measured by both ABD and radionuclide ventriculography (RVG). ABD‐EF was recorded for 25 consecutive heart beats in the apical four‐chamber view. Data were analyzed statistically by linear regression, Bland‐Altman plot, and ROC. In ROC analysis, abnormal LV function was defined RVG‐EF ≤ 40%.

Results: ABD and RVG showed a moderate correlation in the EF measurements: slope=0.93, intercept=17%, r=0.79 (n = 50). Interbeat variability in ABD was diminished by averaging consecutive beats; standard error of estimate (SEE) decreased from 15.6% without averaging to 12.5% with 25‐beat averaging. Bland‐Altman analysis indicated that ABD‐EF compared unfavorably with RVG‐EF, with limits of agreement from ‐11% to 39%. ABD‐EF showed a systematic overestimation (p<0.005), which was compensated by increasing the threshold for abnormal ABD‐EF to 56%. With the optimized threshold, ABD‐EF provided 89% sensitivity and 89% specificity (85% overall diagnostic accuracy) for diagnosing abnormal LV function.

Conclusion: This study explored the limitations of on‐line echocardiographic measurement of EF in a clinical setting and provided useful data for assessing interbeat variability, sensitivity, and specificit.
Symptomatic improvement and reduced hospitalization for patients attending a cardiomyopathy clinic
Authors: Smith Larry E. , Fabbri Sharon A. , Pai Ramdas , Ferry David , Heywood J. Thomas
Published: February 2009

Background: The major costs associated with the management of congestive heart failure (CHF) are inpatient costs. Outcome studies are therefore important to establish whether intensive outpatient care for heart failure can reduce these costs while at the same time improving outcomes in this disabling disorder.

Hypothesis: Care delivered in a cardiomyopathy clinic might result in objective improvement in cardiac function and symptoms while reducing hospital admissions and emergency department visits.

Methods: The outcomes of 21 patients treated for 6 months in a cardiomyopathy clinic are evaluated. New patients referred to the clinic with ejection fraction (EF) <0.45 were enrolled. The Minnesota Living with Heart Failure questionnaire was completed at initial and final visits. All patients underwent baseline and final echocardiogram, radionuclide left ventriculogram, and cardiopulmonary exercise testing. Patients were followed by a nurse practitioner and a cardiologist with maximization of standard treatment. Congestive heart failure‐related hospitalizations and clinic and emergency room visits for both 6‐month periods before and during the study were determined.

Results: There was significant (p<0.05) improvement in these parameters: Heart failure score increased 23 points; New York Heart Association class decreased from 2.6 to 2.2; EF increased from 0.24 to 0.36; diastolic and systolic left ventricular dimensions decreased from 65 to 59 mm and from 57 to 50 mm, respectively. The number of clinic visits increased 5‐fold, whereas there were 86% (14 to 2, p = 0.017) and 100% (8 to 0, p = 0.002) reductions in the number of CHF hospitalizations and emergency visits. There was one death during follow‐up.

Conclusion: Managing patients in a cardiomyopathy clinic may result in a better quality of life, with both symptomatic improvement and decreased hospitalizations.
Aortic valve aneurysm after acute endocarditis
Authors: Plein D. , Van Camp G. , Derluyn M. , Vandenbossche J.‐L.
Published: February 2009

Endocarditis at the aortic level is usually characterized by the presence of a vegetation or an abscess on echocardiography. This paper reports on what is believed by the authors to be the first case of endocarditis presenting as an aneurysmal deformation of one aortic cusp without a vegetation.
Long‐term prognosis of young patients after myocardial infarction in the thrombolytic era
Authors: Füllhaas Jörg‐Uwe , Rickenbacher Peter , Pfisterer Matthias , Ritz Rudolf
Published: February 2009

Background: Myocardial infarction (MI) in young adults is a rare event. In the Framingham study, the 10‐year incidence rate of MI per 1,000 was 12.9 in men 30–34 years old. Overall, 4–8% of patients with acute MI are ≤ 40 years old.

Hypothesis: It was the purpose of this study to assess the in‐hospital and long‐term morbidity and mortality in patients ≤40 years old with acute myocardial infarction compared with older patients in the thrombolytic era.

Methods: A consecutive series of 75 patients aged ≤40 years (mean 35.0 ± 4.8) with acute myocardial infarction was compared with an equally sized group of patients aged >40 years (mean 65.1 ± 9.8).

Results: Thrombolysis or direct percutaneous transluminal coronary angioplasty was performed in 52 versus 24% (p = 0.0004) and 5.3 versus 2.7% (p = NS) in younger and older patients, respectively. Significantly fewer young patients had multivessel disease (28 vs. 64%, p < 0.004). No in‐hospital mortality was observed in patients with reperfusion therapy irrespective of age. After a mean followup time of 47 ± 35 months, cardiac mortality was 0 and 11% (p < 0.03), respectively, in young and older patients with, and 3 versus 24% (p < 0.02) without reperfusion therapy, respectively. In addition, significantly fewer patients in the younger age group developed recurrent angina pectoris (12 vs. 39%, p = 0.0004) or congestive heart failure (9 vs. 34%, p = 0.0005) irrespective of reperfusion therapy.

Conclusion: Our observations demonstrate that long‐term prognosis after myocardial infarction in young patients is excellent in the thrombolytic era.