bluuebunny/crossref_metadata_2025 huggingface dataset:
Percutaneous transvenous mitral commissurotomy versus surgical commissurotomy in the treatment of mitral stenosis
Authors: Lau Kean‐Wah , Ding Zee‐Pin , Hung Jui‐Sung
Published: February 2009

There is no doubt that percutaneous transvenous mitral commissurotomy (PTMC) in experienced centers is associated with a low risk of major complications and yields excellent immediate and long‐term outcome. Although previous observational studies on both PTMC and surgical commissurotomy have indicated similar outcome between the two treatment strategies in terms of valve area improvement and risk of major complication (death, thromboembolism and significant resultant mitral regurgitation), it was not until recently that several prospective randomized trials comparing the two procedures and involving >470 patients with favorable valve characteristics (pliable, noncalcified valve with mild sub‐valvular disease and no or mild mitral regurgitation), have confirmed that PTMC is indeed just as, if not more, effective as surgical commissurotomy. The late restenosis rate at up to 3‐year follow‐up appears comparable. Furthermore, PTMC has other additional benefits. It is nontraumatic, may be repeated without additional risk, and has been shown to be an extremely useful and efficacious palliative tool in those with end‐stage mitral stenosis or with unfavorable valve anatomy who refuse surgery, and in certain subset of patients at high surgical risk because of medical comorbidities.
Safety of a new transpulmonary echocontrast agent (albunex®) in repeated echocardiographic studies in patients
Authors: Geny B. , Piquard F. , Haberey P. , Bischoff P. , Müan B. , Lambrechs M. , Juelsrud‐Vebner A. , Thiranos J. C. , Epailly E. , Eisenmann B.
Published: February 2009

Background and hypothesis: Multiple contrast‐enhanced echocardiographic studies are to be expected in patients with cardiac ischemic disease, but the sonication process used to produce the echocontrast agent Albunex® may result in new epitopes that could cause an immunogenic response.

Methods: Repeated exposures to intravenous Albunex over a period of time long enough to allow development of an eventual immune reaction were performed in 12 patients while monitoring for lymphocyte transformation, microsphere specific IgE and IgG antibodies, and systemic, pulmonary artery, capillary wedge, and right atrial pressures, as well as cardiac output, left ventricular fractional shortening, and blood gases.

Results: No significant 3H‐thymidine incorporation and thus no specific blastic transformation of the patients' lymphocytes were observed either for high or low Albunex concentrations, corresponding to the expected hepatic and plasma concentrations of microspheres. No formation of micro‐sphere‐specific IgE and IgG antibodies was observed after the first or second Albunex exposure. Furthermore, no clinically significant hemodynamic or respiratory adverse reactions were observed in any patient.

Conclusion: These results suggest that repeated exposures to intravenous Albunex induce no adverse effect on the cellular and humoral immune systems and on left and right heart hemodynamics in patients.
Unexplained chest pain: When is it panic disorder?
Authors: Fleet Richard P. , Beitman Bernard D.
Published: February 2009

Noncardiac chest pain is a common costly phenomenon in the cardiology setting. Recent research suggests that panic disorder, a highly distressful yet treatable anxiety disorder, occurs in a significant proportion of noncardiac chest pain patients. This article reviews research on the prevalence of panic disorder in patients seen in cardiology settings for unexplained chest pain. Financial, psychosocial, and historical aspects of noncardiac chest pain are described. Panic disorder and the potential consequences of its nonrecognition by physicians are examined. Current psychological and pharmacologic treatments are reviewed. Recommendations on the management of panic patients in the cardiology setting are provided.
Alcohol, ischemic heart disease, and the french paradox
Authors: Constant Jules
Published: February 2009

Many studies have shown either an inverse relation between alcohol intake and ischemic heart disease or a U‐shaped curve in which the equivalent of two drinks per day of any kind of alcohol is associated with a decreased incidence of coronary disease compared with no drinks, while higher doses result in an increased risk of infarction and stroke. Although the cardioprotective effects of most alcoholic beverages are probably due to an elevation of high‐density lipoprotein as well as the ability of alcohol to prevent platelet aggregation and increased fibrinolysis, there is an increased favorable effect of red wine. The unique cardioprotective properties of red wine reside in the action of flavonoids which are absent in white wine (with the exception of champagne) and sparse in beer (with the exception of dark beers). The best researched flavonoids are resveritrol and quercetin, which confer antioxidant properties more potent than alpha‐tocopherol. Grape juice has about half the amount of flavonoids by volume as does red wine.
Determinants of coronary vascular disease in patients with type ii diabetes mellitus and their therapeutic implications
Authors: Schneider David J. , Sobel Burton E.
Published: February 2009

Cardiovascular morbidity and mortality are increased 4‐ to 6‐fold in patients with type II diabetes. The high prevalence is multifactorial and reflects in part the adverse influence of covariate, cardiac risk factors such as hypertension and hyperlipidemia. Type II diabetes is characterized by insulin resistance, hyperinsulinemia, and altered carbohydrate and lipid metabolism resulting in hyperglycemia, increased concentrations in blood of very low‐density and low‐density lipoproteins, and decreased blood high‐density lipoproteins. Abnormalities seen predispose to vasculopathy through lipid deposition into vessel walls associated with monocyte infiltration, vascular smooth muscle cell proliferation, arterial mural fibrosis, and thrombosis. Conventional therapy for cardiovascular disease such as angioplasty and bypass surgery are of only limited efficacy. Thus, retardation of progression of atherosclerosis is essential. In addition to focusing on coexistent cardiac risk factors such as hypertension, therapy for patients with type II diabetes should reduce or reverse insulin resistance, improve metabolic control, and, ideally, do so without exacerbating hyperinsulinemia. Diet and exercise are central, and novel orally active hyperglycemic agents such as the biguanides and the thiazolidinediones that sensitize diverse tissues to insulin offer particular promise.
Double‐blind randomized multicenter study on the efficacy of trapidil versus isosorbide dinitrate in stable angina pectoris
Authors: Raubach K.‐H. , Vlahov V. , Wolter K. , Bussmann W.‐D.
Published: February 2009

Background: Trapidil is an inhibitor of phosphodiesterase I‐IV with resulting positive lusitropic, vasodilating, and antiplatelet effects.

Hypothesis: This study was undertaken to compare the antianginal efficacy of trapidil with that of isosorbide dinitrate (ISDN) in patients with stable angina pectoris.

Methods: We studied 95 patients with stable angina pectoris who were randomized into a double‐blind parallel group study with either oral trapidil or ISDN. After a 1‐week run‐in period and a 2‐week wash‐out phase, the patients received either trapidil 200 mg t.i.d. (n = 48) or ISDN 20 mg t.i.d. (n = 47) for 12 weeks. All antianginal medication, except sublingual glyceryl trinitrate (GTN), was discontinued during the study. Patients underwent an exercise electrocardiogram on an ergometer bicycle according to a modified Bruce protocol before and at 6 and 12 weeks during treatment.

Results: The workload capacity increased from 583 ± 281 W‐min before treatment to 833 ± 444 W‐min after 12 weeks of treatment in the trapidil group (p<0.01) and from 555 ± 276 W‐min to 827 ± 361 W‐min in the ISDN group (p<0.01). The anginal attacks per week as well as the use of GTN decreased significantly in both groups. After 12 weeks of therapy, the cumulative ST‐segment depression during exercise decreased by 67% in the trapidil patients and by 23% in the ISDN patients. Compared with baseline, the double product at the 75 W level was reduced in both groups after 12 weeks of treatment. Blood pressure and heart rate at rest remained nearly unchanged. Overall, no statistical difference was found between the two study groups. The tolerability was good.

Conclusion: Oral trapidil therapy is safe and effective in stable angina pectoris and is equivalent to standard therapy with ISDN.
QT dispersion ratio in patients with unstable angina pectoris (A new risk factor?)
Authors: Cin V. G. , Celik M. , Ulucan S.
Published: February 2009

Background: QT dispersion has been shown to be associated with fatal arrhythmias and sudden death in coronary artery disease. A recent study indicated that marked QT dispersion in electrocardiograms (ECGs) obtained during acute ischemia demonstrated a significant correlation with ventricular fibrillation.

Hypothesis: This study investigated the ECG parameters for repolarization (QT dispersion, corrected QT, corrected QT dispersion, and QT dispersion ratio) and their interrelation with acute ischemia.

Methods: QT parameters as well as a newly developed repolarization index, QT dispersion ratio l(QT dispersion/RR interval) × 100] were calculated digitally during rest and ischemia in 32 patients with coronary artery disease (rest angina, Braunwald class III). Results were correlated with clinical consequences, mainly arrhythmias, within a follow‐up period of 5±2days.

Results: While most patients had an increase in all four parameters, only the QT dispersion ratio showed a significant difference when correlated with ventricular arrhythmias (p < 0.001, F ratio = 38).

Conclusion: QT dispersion ratio appears to be a new and promising parameter in predicting ventricular arrhythmias in patients with acute ischemia.
Contemporary issues in rate‐adaptive pacing
Authors: Barold S. Serge , Barold Helen S. , Camm A. John
Published: February 2009

This review addresses a number of questions pertaining to contemporary rate‐adaptive pacemakers that include the role of dual sensor systems, sensor blending and cross‐checking, automaticity, nonrate‐related sensor functions, prevention of arrhythmias, and several other areas of clinical importance.
Hyperglycemia‐induced angina pectoris in a patient with diabetes mellitus
Authors: Lickerman Alex , Grover‐Mckay Maleah , Dellsperger Kevin C.
Published: February 2009

A patient with diabetes mellitus and coronary artery disease presented with recurring episodes of worsening angina not associated with angiographic changes. Correlation with blood sugars demonstrated that angina would occur during episodes of hyperglycemia. During cardiac catheterization, coronary vascular responses including coronary flow reserve and responses to atrial pacing were measured with a Doppler flow wire before and following a glucose challenge. Coronary microvascular responses were impaired by hyperglycemia.
Rapid myoglobin analysis to assess coronary artery reperfusion after acute myocardial infarction
Authors: Lee Hai Shiang , Cross Stephen J. , Jennings Kevin
Published: February 2009

Background: Coronary artery reperfusion significantly improves outcome in patients with acute myocardial infarction. A noninvasive method for assessing reperfusion in the early stage of infarction should be helpful in patient management.

Hypothesis:We sought to assess whether release pattern of myoglobin is helpful in identifying patients with and without reperfusion following thrombolytic therapy for myocardial infarction.

Methods: Myoglobin was measured before thrombolysis, half hourly for 4 h, then every 2 h for 10 h. Myoglobin was analyzed using a ward‐based “rapid” and automated analyzer that yielded quantitative results within 10 min of blood collection.

Results: In the 15 patients with coronary reperfusion, the time from thrombolysis to peak myoglobin levels (mean ± SD, 2.4 ± 1.5 h) was significantly lower than in nonreperfused patients (5.1 ± 2.9, p < 0.01). As an indicator for reperfusion, a doubling of myoglobin 1 h after streptokinase achieved a sensitivity of 80%, a specificity of 80%, and a predictive accuracy of 80%.

Conclusions: The difference in myoglobin release kinetics is useful in identifying patients without coronary reperfusion and should aid in their management.
Retroperitoneal fibrosis and infection of an aortic graft prosthesis: Diagnosis and therapeutic problems
Authors: Cuny C. , Chauffert B. , Lorcerie B. , Martin F.
Published: February 2009

The occurrence of a retroperitoneal fibrosis (RPF) after an aorto‐bifemoral bypass is unusual. A case of RPF as a complication of an infection of the graft prosthesis is reported. Computed tomography and magnetic resonance imaging prove useful in diagnosing graft infection: they may reveal periprosthetic gas or perigraft fluid persisting for several months after surgery. However, they may fail when they are performed too early, and repeat performance is suggested.
Echocardiographic characteristics and causal mechanism of physiologic mitral regurgitation in young normal subjects
Authors: Mishiro Yuichiro , Ishimoto Takeo , Oki Takashi , Iuchi Arata , Tabata Tomotsugu , Yamada Hirotsugu , Manabe Kazuyo , Fukuda Kazuyo , Abe Miho , Onose Yukiko , Ito Susumu
Published: February 2009

Background: It has become evident that mitral regurgitation (MR) is not uncommon in healthy subjects, and Doppler color flow mapping is a technique that imparts important information relevant to its detection.

Hypothesis: Using transthoracic echocardiography, this study evaluated the mechanism of physiologic MR in young normal subjects using transthoracic echocardiography.

Methods: The study population consisted of 48 young normal subjects (mean 21 ± 5 years) with MR (physiologic MR group), 40 age‐matched young normal subjects (mean 20 ± 5 years) without MR (control group), 45 patients (mean 41 ± 15 years) with mitral valve prolapse with MR (MVP group), and 27 patients (mean 59 ± 13 years) with ruptured chordae tendineae (rupture group).

Results: Men were predominant in the rupture group, whereas there were no significant gender differences in the other three groups. Left ventricular end‐diastolic dimension and left atrial systolic dimension were slightly smaller in the physiologic MR group than in the control group, but were significantly smaller than those in the MVP and rupture groups. The ratio of the maximum anteroposterior diameter to the maximum transverse diameter on chest radiography and the ratio of the short‐ to long‐axis diameter of the left ventricular cavity at end diastole, determined from two‐dimensional short‐axis echocardiogram, were significantly lower in the physiologic MR group than in the other three groups. Mitral regurgitation occurred more frequently at the posteromedial commissural site in the physiologic MR and MVP groups, whereas there was no preference for location in the rupture group. Early systolic MR was often observed in the physiologic MR group, whereas pansystolic MR was common in the MVP and rupture groups.

Conclusion: As a causal mechanism for physiologic MR detected in young normal subjects, “flattening” of the thorax during growth may cause morphologic abnormalities of the left atrial and ventricular cavities, resulting in spatial imbalance of the mitral complex and resulting in malcoaptation of the valve.
Isolated right ventricular infarction presenting as anterior wall myocardial infarction on electrocardiography
Authors: Porter Avital , Herz Itzhak , Strasberg Boris
Published: February 2009

Isolated right ventricle infarction is extremely rare, and its electrocardiographic (ECG) signs may be misinterpreted or even missed, especially when a typical clinical picture is lacking. This paper describes a case of isolated right ventricle infarction, recognized only by echocardiography. The patient presented with ST‐segment elevation in left precordial leads together with minimal ST‐segment elevation in inferior leads on a 12‐lead ECG. Angiography revealed the culprit right coronary artery, which was small and non‐dominant. No significant obstructions were found in the left anterior descending artery. This case demonstrates that the ECG appearance of isolated right ventricle infarction may mimic anterior wall infarction and can be easily missed if not suspected.
Rapid hemostasis of arterial puncture sites with collagen in patients undergoing diagnostic and interventional cardiac catheterization
Authors: Silber Facc Sigmund ,
Published: February 2009

Despite the continuous reduction of sheath sizes in diagnostic and interventional cardiac catheterizations and the discontinuation of coumadin use after coronary stent implantation, a challenging role remains for hemostatic devices in the sealing femoral puncture sites. Since the introduction of the vascular hemostatic device (VHD) in 1991 and the hemostatic puncture closing device (HPCD) in 1992, numerous studies investigating these devices have been published. The deployment success rates reported in 2,292 patients for VHD is 97%, ranging from 88 to 100%. For HPCD, the mean deployment success rate resulting from 622 published patients leads to an identical result of 97%, ranging between 91 and 100%. For time to hemostasis, data have been analyzed according to the four different clinical situations, depending on level of anticoagulation (none or full) and the time of sheath removal (immediate or delayed). In randomized studies, when compared with the manual control groups, both devices revealed a statistically significant reduction in time to hemostasis: 12 to 16 minutes less for diagnostic catheterization and 14 to 30 minutes less for PTCA. As for minor local complications, no clinically relevant differences seem to exist. None of these devices has been proven to reduce major local complications. Prospective trials addressing early mobilization after percutaneous transluminal coronary angioplasty and the cost effectiveness of arterial closure devices in defined subgroups are warranted.
Myocardial bridge as a cause of thrombus formation and myocardial infarction in a young athlete
Authors: Agirbasli Mehmet , Martin Gregory S. , Bunker Stout J. , Jennings Henry S. , Lea John W. , Dixon John H.
Published: February 2009

We report here a young male athlete who had an acute myocardial infarction after strenuous exercise. Coronary angiography clearly demonstrated thrombus formation within a prominent myocardial bridge. Periarterial resection surgery was performed, which resulted in resolution of the angiographic “milking” effect of muscle bridge. Our observation. along with previous reports, suggests that myocardial bridges should be added to the list of known causes of sudden death or myocardial infarction in young persons after strenuous exercise. Thrombus formation within a myocardial bridge may be a potential mechanism whereby this anatomic curiosity may cause a tragic clinical event.
Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation
Authors: Oki Takashi , Tabata Tomotsugu , Yamada Hirotsugu , Wakatsuki Tetsuzo , Fukuda Kazuyo , Abe Miho , Onose Yukiko , Iuchi Arata , Ito Susumu , Fukuda Nobuo
Published: February 2009

Background: The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling.

Hypothesis: The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation.

Methods: We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm.

Results: Mean pulmonary capillary wedge pressure, V‐wave height in the pulmonary capillary wedge pressure curve, and left ventricular end‐diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time‐velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time‐velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V‐wave height were comparatively constant when the preceding R‐R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R‐R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy.

Conclusion: Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.
Circadian rhythm of autonomic activity in patients with obstructive sleep apnea syndrome
Authors: Noda Akiko , Yasuma Fumihiko , Okada Tamotsu , Yokota Mitsuhiro
Published: February 2009

Background and hypothesis: Although the immediate effects of sleep apnea on hemodynamics and the neurological system have been studied, little is known about the circadian rhythm of heart rate variability in patients with obstructive sleep apnea syndrome (OSAS). The purpose of the present study was to investigate the effects of sleep apnea on the autonomic activity during daytime, which may play some role in the pathogenesis of cardiovascular complications in OSAS.

Methods: We studied 18 middle‐aged male patients with OSAS and 10 age‐matched control subjects. Patients with OSAS were classified according to the severity of OSAS: patients with an apnea index (AI) < 20 were considered to have mild OSAS (Group 1, n = 8) and patients with an AI≥ 20 were considered to have severe OSAS (Group 2, n = 10). Heart rate variability was calculated from the 24‐h ambulatory electrocardiograms by the Fourier transformation. Power spectra were quantified at 0.04‐0.15 Hz [low frequency power (LF)ln(ms2)] and 0.15‐0.40Hz [high frequency power (HF)ln(ms2)]. The HF component and the ratio of LF to HF were used as indices of the parasympathetic and sympathetic activity, respectively.

Results: The circadian rhythms of the LF, HF, and LF/HF ratio differed significantly in Group 2 compared with Group 1 and control subjects (p<0.05). Hypertension (>160/95 mm Hg) was found in 7 (70.0%) of 10 patients in Group 2, and in 1 (12.5%) of 8 patients in Group 1. Echocardiographic evidence of left ventricular hypertrophy (LVH) (an interventricular septal thickness or a left ventricular posterior wall thickness ≥ 12 mm) was found in 3 (30.0%) of 10 patients in Group 2, and in 1 (12.5%) of 8 patients in Group 1. The mean HF from 4 A.M. to 12 noon was significantly lower in Group 2 than in Group 1 and the control group, and it correlated significantly with the lowest nocturnal SaO2 (r = 0.58, p<0.05). The mean LF/HF ratio during the same period was significantly higher in Group 2 than in Group 1 and the control group, and it correlated significantly with total time of the nocturnal oxygen saturation <90% (r = 0.64, p<0.005) and the lowest nocturnal SaO2 (r = 0.56, p<0.05). Ventricular tachycardia was found in the early morning in one patient, ST‐T depression in two patients, and sinus arrest in two patients in Group 2.

Conclusion: These findings suggest that sleep‐disordered breathing associated with severe oxygen desaturation might influence heart rate variability not only during sleep but also during daytime. OSAS per se might contribute to altered circadian rhythm in autonomic activity leading to the development of cardiovascular diseases.
Influence of tissue affinity of angiotensin‐converting enzyme inhibitors on left ventricular remodeling after myocardial infarction
Authors: Konermann M. , Altmann C. , Laschewski F. , Josephs W. , Odenthal H. J. , Horstmann E. , Sanner B.
Published: February 2009

Background: The demonstration of local renin‐angiotension systems has raised the question of whether angiotensinconverting enzyme (ACE) inhibitors with different tissue affinities differ with regard to their effects on postinfarction remodeling.

Hypothesis: The study was undertaken to investigate the influence of ACE inhibitors with different tissue affinity on morphology and function of the infarcted left ventricle.

Methods: In all, 52 patients (17 women, 35 men, 38‐73 years) with large acute myocardial infarction were randomized to receive either 25‐75 mg/day captopril or 10‐20 mg/day fosinopril beginning on the Day 7 after infarction. Of these, 28 had anterior and 24 had posterior wall infarctions. Infarct size was determined by the creatine kinase integral method. Fifty patients were examined by cinemagnetic resonance imaging (CMRI) 1 and 26 weeks after infarction. The following parameters were determined: left ventricular enddiastolic and end‐systolic volume index (LVEDVI, LVESVI), ejection fraction (LVEF), infarct weight, and muscle mass (LVMM). The volume‐to‐mass ratio (VMR) was calculated and the clinical status according to the guidelines of the New York Heart Association (NYHA) was documented at each examination time. The results were compared with those of a historical sample without ACE‐inhibitor therapy examined in an identical manner (n = 31, 10 women, 21 men, 36‐75 years).

Results: LVEDVI and LVESVI increased in the first 6 months after infarction by 24.9 and 36.6%, respectively, in the historical sample; by 11.0 and 7.8%, respectively, under captopril; and by 13.1 and 10.7%, respectively, under fosinopril. LVEF decreased by 14.9% in the untreated sample, by 3.7% under captopril and by 5.0% under fosinopril. Infarct weight and LVMM increased by 12.7 and 15.3%, respectively, without ACE inhibition, by 5.7 and 10.1%, respectively, in patients treated with captopril, and by 6.1 and 9.3%, respectively, in patients treated with fosinopril. The VMR increased by 7.4% in the historical sample, by 3.5% in the captopril group, and by 1.8% in the fosinopril group. The NYHA clinical status improved by 18.2% without ACE inhibition, by 42.9% in the captopril group, and by 26.3% in the fosinopril group. The differences between the two ACE‐inhibitor groups and the reference group were all significant, while the differences between the captopril group and the fosinopril group were significant only for VMR (p<0.01) and NYHA class (p < 0.05).

Conclusions: Both captopril and fosinopril have a comparable positive influence on postinfarction remodeling and on clinical status. Lipophilicity and tissue affinity do not seem to play a clinically important role in ACE‐inhibitor therapy after infarction.
Rupture of mitral chorda tendinea following blunt chest trauma
Authors: Grinberg Alejandro Rubén , Finkielman Javier Daniel , Piñeiro Daniel , Festa Hector , Cazenave Claudio
Published: February 2009

Acute mitral insufficiency, originated from rupture of mitral chordae tendineae secondary to nonpenetrating thoracic trauma, is an unusual condition. This diagnosis is difficult to establish because physical examination, electrocardiogram, and cardiac enzymes are neither sensitive nor specific. The diagnosis of rupture must be quickly established because this disorder may be fatal. This paper reports the case of a patient with acute mitral insufficiency secondary to a mitral valve chord rupture a week after a nonpenetrating thoracic trauma.
Pulmonary embolism and impending paradoxical embolism: A role for transesophageal echocardiography?
Authors: Alexiou C. , Richens D. , Henderson R. A.
Published: February 2009

Thrombolysis is advocated as the treatment of choice for hemodynamically important pulmonary embolism. This paper reports the case of a patient with subacute massive pulmonary embolism in which thrombolysis was not considered appropriate because transesophageal echocardiography demonstrated a patent foramen ovale and impending paradoxical embolism.
Simultaneous manifestation of acute myocardial infarction and nephrotic syndrome
Authors: Meyer Thomas , Schulze Friederike , Kreuzer Heinrich , Grone Hermann‐Josef
Published: February 2009

This report describes the simultaneous manifestation of ischemic heart disease and nephrotic syndrome in a 37‐year‐old woman presenting with acute anterior myocardial infarction. Symptoms of nephrotic syndrome, such as facial and peripheral edema accompanied by proteinuria and hyperlipidemia, and onset of severe retrosternal pain developed within 24 h. Coronary angiography revealed a complete thrombotic occlusion of the proximal portion of the left anterior descending artery with no evidence of arteriosclerotic lesions. Histologic examination of renal biopsy, including electron microscopy, revealed evidence of minimal change glomerulonephritis. Ultrastructural studies demonstrated widespread effacement of epithelial foot processes. Elevated levels of circulating fibrinogen appeared to be an important factor for the hypercoagulable state in this patient, suggesting a causative relationship between coronary thrombosis and nephrotic syndrome.
Acute profound thrombocytopenia after abciximab therapy during coronary angioplasty
Authors: Joseph T. , Marco J. , Gregorint L.
Published: February 2009

Since the extensive use of abciximab, a potent antiplatelet agent directed against GP IIb/IIIa platelet receptors, to prevent ischemic complications of percutaneous transluminal coronary angioplasty, few cases of thrombocytopenia have been observed. This paper reports a case of acute profound thrombocytopenia (platelet count: 800/mm3) occurring 16 h after abciximab therapy during coronary angioplasty. As thrombocytopenia occurrence is not predictable, platelet count should be evaluated periodically after drug administration. Mechanisms of this adverse effect remain unknown. Platelet transfusion results in a rapid and sustained improvement of platelet count, avoiding the occurrence of major hemorrhagic complications.
The role of cardiac Troponin‐I (cTnI) in risk stratification of patients with unstable coronary artery disease
Authors: Tanasijevic Milenko J. , Cannon Christopher P. , Antman Elliott M.
Published: February 2009

In patients with chest pain at rest but no ST‐segment elevation on the electrocardiogram, the diagnoses of unstable angina and non‐Q‐wave myocardial infarction (MI) are usually considered together because they cannot be differentiated clinically or angiographically. Since the extent of myocardial necrosis is an important determinant of the risk of death, it is important to identify serum markers with which to predict prognosis, in order to initiate appropriate medical treatment and/or invasive procedures in these patients. Cardiac troponin‐I (cTnI), one of the subunits of the troponin regulatory complex, binds to actin and inhibits interactions between actin and myosin. The presence of elevated cTnI in serum is a significant prognostic indicator in patients with unstable angina and non‐Q wave MI. Its independent prognostic potential persists even after adjustment for independent baseline variables known to be significantly associated with an increased risk of cardiac events. The use of cTnI in the triage of patients with unstable coronary disease may identify those at greater risk for adverse cardiac events.
Constrictive pericarditis
Authors: Mehta Anurag , Mehta Mahaveer , Jain Abnash C.
Published: February 2009

The diagnosis of constrictive pericarditis remains a challenge because its physical findings and hemodynamics mimic restrictive cardiomyopathy. Various diagnostic advances over the years enable us to differentiate between these two conditions. This review begins with a case report of constrictive pericarditis, followed by a brief history and discussions of etiologies. Clinical features, radiologic, electrocardiographic, angiographic findings, and hemodynamics of constrictive pericarditis are reviewed. The echocardiographic findings are detailed and the recent advances in Doppler flow velocity patterns of pulmonary, mitral, tricuspid valves and hepatic veins are reported. Nuclear ventriculograms depict rapid ventricular filling in constrictive pericarditis and differentiate it from restrictive cardiomyopathy. Endomyocardial biopsy helps further in recognizing the various types of restrictive cardiomyopathies. Computed tomography and magnetic resonance imaging delineate abnormal pericardial thickness in constrictive pericarditis. Association of characteristic hemodynamic changes and abnormal pericardial thickness >3 mm usually confirms the diagnosis of constrictive pericarditis. Effusive and occult varieties of constrictive pericarditis are briefly described. This review concludes with emphasizing the importance of pericardial resection.
Diagnostic potential of combined transthoracic echocardiography and x‐ray computed tomography in suspected aortic dissection
Authors: Kodolitsch Yskert V. , Krause Norbert , Nienaber Christoph A. , Spielmann Rolf
Published: February 2009

Background: Transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are considered optimal diagnostic methods in the setting of suspected aortic dissection. However, although less sensitive as single modalities, transthoracic echocardiography (TTE) and contrast‐enhanced computed tomography (x‐ray CT) are more widely available and less costly.

Hypothesis: This study was undertaken to compare the diagnostic performance and reliability of the combined use of TTE and x‐ray CT with TEE and/or MRI findings in the setting of suspected aortic dissection.

Methods: The diagnostic power of combined TTE and x‐ray CT was compared with both single use of TTE and x‐ray CT and with TEE and/or MRI in a series of 168 consecutive patients with suspected aortic dissection (AD). Of these, 28 women and 58 men (mean age 53 ± 16 years) underwent TTE and x‐ray CT prior to TEE (n = 52) and/or MRI (n = 69). Diagnostic results of combined TTE/x‐ray CT were retrospectively but independently reevaluated in blinded fashion; diagnostic findings were validated by angiography (n = 63), surgery (n = 52), or autopsy (n = 7).

Results: Type A dissection was found in 29 patients (34%), type B dissection in 10(12%), whereas aortic dissection was excluded in 47 (55%). With 95%, the sensitivity of TTE and x‐ray CT was significantly enhanced when used in a combined access compared with 67 and 79%, respectively, when used as single methods (95%; p < 0.05). Sensitivity and specificity (95 and 91%, respectively) of combined TTE/x‐ray CT evaluation were not different from TEE and/or MRI (100 and 96%, respectively; NS). Thrombus formation, side‐branch involvement, aortic regurgitation, pericardial effusion or mediastinal hematoma were also detected with similar sensitivities and specificities both by combined TTE/x‐ray CT and TEE and/or MRI.

Conclusion: This first controlled study comparing the combined information of TTE and x‐ray CT with TEE and/or MRI revealed a similar diagnostic potential of both diagnostic strategies in the setting of suspected aortic dissection. Thus, in an environment with access to color Doppler TTE and x‐ray CT only, the information from both tests should be combined to decide on diagnostic management of these patients.
Weight gain and insulin resistance during nicotine replacement therapy
Authors: Assali A. R. , Beigel Y. , Schreibman R. , Shafer Z. , Fainaru M.
Published: February 2009

Background: Although the cessation of smoking reduces the increased risk for ischemic heart disease, it is associated with marked weight gain and presumably insulin resistance, both of which heighten the risk of coronary heart disease.

Hypothesis: We investigated the isolated effect of nicotine on body weight and insulin resistance during smoking cessation.

Methods: Eleven healthy, middle‐aged heavy smokers were studied. Insulin sensitivity was assessed by an insulin‐enhanced, frequently sampled intravenous glucose tolerance test with minimal model analysis. The subjects were studied at baseline (last day of smoking) (phase 1), at the end of the 6‐week nicotine replacement program (phase 2), and after 8 weeks without smoking or nicotine replacement (phase 3).

Results: The subjects started to gain weight during nicotine replacement (phase 2) (0.3 ± 0.2 kg/week, mean ± standard deviation) and continued to do so at a steady rate after nicotine replacement was stopped (0.2 ± 0.2 kg/week) (p = 0.3). Insulin sensitivity decreased by 14 ± 2.6% during nicotine replacement but increased by 16 ± 5.1% (compared with phase 2) during phase 3, even though the weight gain continued (p = 0.047; 95% confidence interval: 0.05–5.73).

Conclusions: Smoking cessation is associated with weight gain and improvement in insulin resistance. Nicotine is the main ingredient in cigarette smoke causing insulin resistance, but the withdrawal of another, unknown ingredient in cigarette smoke is responsible for the weight gain associated with smoking cessation.
Spontaneous coronary artery dissection: Favorable outcome illustrated by angiographic data
Authors: Longheval G. , Badot V. , Najioullah S. , Cosyns B.
Published: February 2009

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It typically occurs in young women receiving oral contraceptive therapy or during the peripartum period. in the case presented here, spontaneous complete healing at angiography and the favorable outcome may support the role of conservative treatment in such patients.
Surgical repair of tetralogy of fallot in adults today
Authors: Dittrich Sven , Vogel Michael , Dähnert Ingo , Berger Felix , Lange Pete R. E. , Alexi‐Meskishvili. Vladimir
Published: February 2009

Background: Today, corrective surgery of native tetralogy of Fallot beyond childhood is a rare exception. in the years following the fall of the Berlin wall, 22 adults with uncorrected tetralogy presented to our center, mostly from former Eastern Block countries.

Hypothesis: Our aim was to examine whether adults with tetralogy of Fallot benefit from late surgical repair. Nineteen patients underwent corrective surgery; hospital mortality was 16%. Follow‐up examination 3.5 (0.3–9.7) years postoperatively consisted of chart review and a written questionnaire. Incidence of ventricular arrhythmias was 32% before surgery and increased to 50% 3.5 years after surgery. Clinical status and New York Heart Association classification were clearly improved. This was not reflected in an improvement of the patients' socioeconomic status, as none of the 9 patients in our group of 19, who were jobless before the surgery, experienced a change in employment status. Marital status did not change in any patient and, in particular, the number of single male patients remains high. Except for one nearly asymptomatic younger woman who had delivered four children, only one of the seven married women had delivered a child before and one of the younger women after cardiac repair, which we consider to be a positive effect of this surgery. Surgical correction of adult patients with tetralogy of Fallot carries a higher risk compared with correction in childhood. It improves quality of life but does not change socioeconomic habits.
Reactivity of peripheral blood lymphocytes to oxidized low‐density lipoprotein: A Novel system to estimate atherosclerosis employing the cellscan
Authors: Zurgil N. , Levy Y. , George J. , Gilburd B. , Shoenfeld Y. , Deutsch M. , Kaufman M. , Harats D.
Published: February 2009

Background: The assumption that atherosclerosis involves an autoimmune response to oxidized LDL (oxLDL) is based on the presence of immunocompetent cells and immunoglobulin deposition in the atherosclerotic lesions by successful immunomodulation of the atherosclerotic process and by inhibition of experimental atherosclerosis by antioxidants. The Cellscan system is a multiparameter laser‐based static cytometer that enables repeated monitoring of the fluorescence intensity (FI) and polarization (FP) of individual living cells. Analysis of intracellular fluorescein fluorescence polarization (IFFP) has previously been used to define activated lymphocyte population.

Hypothesis: In this study, the Cellscan apparatus has been used to monitor cellular response to oxLDL in patients with atherosclerosis and in controls.

Methods: The FI and FP of fluorescein diacetate (FDA)‐labeled peripheral lymphocytes were measured following exposure to oxLDL in vitro. Using cluster analysis we were able to identify subpopulations of cells that were characterized by their FI and FP. Forty‐two subjects were studied: 22 patients with severe coronary heart disease and 22 control individuals, either healthy or with other diseases.

Results: Fluorescence intensity of fluorescein‐labeled peripheral blood lymphocytes (PBL) was markedly decreased upon exposure to high doses (> 25 m̈g/ml) of oxLDL concurrently with an increase in FP. A specific and dose‐dependent reduction in FP of the high‐intensity cell subpopulations, accompanied by higher FI, was evident in patients with ischemic heart disease upon exposure to low doses of oxLDL (up to 25 m̈g/ml). Maximal depolarization was shown upon triggering with 2 m̈g/ml oxLDL. The polarization ratio (the mean polarization value of the specific cell population with and without activation) obtained for patients' lymphocytes was significantly lower (p < 0.01) than that of the control group (0.936 ± 0.05 and 1.028 ± 0.055, respectively).

Conclusion: These data suggest that PBL from patients with active ischemic heart disease show an increased reactivity to oxLDL. A 73% positivity rate was found for ischemic heart disease patients compared with 5% in the control subjects. One of the future prospects of this study might be the advent of a simple and rapid noninvasive test that could assess the extent of atherosclerosis, and possibly even the response to therapy, by monitoring the reactivity of PBL to oxLDL.
Procedural results of coronary angioplasty but not late mortality have improved in patients with depressed left ventricular function
Authors: Lindsay Joseph , Grasa Gabriela , Pinnow Ellen E. , Plude Gail , Pichard Augusto D.
Published: February 2009

Background: Published experience with coronary angioplasty in patients with severely depressed left ventricular (LV) ejection fraction indicates that procedural complications are more frequent in such patients than in those with normal or near normal LV function. Although the immediate outcomes of transcatheter revascularization in unselected populations have improved substantially since the procedures upon which these reports were based were performed, outcomes with this subset of patients has not been recently reviewed.

Hypothesis: This study was undertaken to document the results of the application of current transcatheter technology to this patient subset.

Methods: We analyzed data from 194 consecutive patients with a visually estimated LV ejection fraction < 30%, who underwent coronary angioplasty in this institution between January 1, 1995, and April 30, 1996, and compared their outcomes with those of 1,390 patients with normal LV function treated concurrently.

Results: Angiographic success in the two groups was similar. The hospital mortality of the patients with low ejection fraction was higher (2.6 vs. 0.6%, p=0.02) than in concurrently treated patients with normal LV function. Other procedural complications were no more frequent than in such patients. Late mortality in patients with low ejection fraction was 16%, a similar value to that in older reports.

Conclusion: Compared with older reports, current hospital outcomes of coronary angioplasty are improved in patients with severely depressed LV function. Unfortunately, late outcomes are not demonstrably better.
Platelet‐endothelial interactions in atherothrombotic disease: Therapeutic implications
Authors: Wilson James M. , Ferguson James J.
Published: February 2009

The role of the platelet and the endothelium in the pathogenesis of atherosclerosis and subsequent ischemic events has been the subject of extensive investigation. Arterial sites where endothelial function is severely impaired are often the sites of atheroma development. Lesion evolution impairs endothelial function, leading to a self‐perpetuating cycle of growth. During early lesion development, overt thrombotic events are rare. However, rupture of an advanced, necrotic plaque or intimal ulceration triggers arterial thrombosis, at which point the importance of platelet function may be seen clearly. The Antiplatelet Trialists' Collaboration meta‐analysis demonstrated the benefit of antiplatelet therapy to patients with atherosclerotic disease. Aspirin is the most widely studied agent and is considered the standard of antiplatelet therapy. Newer agents that intervene at different stages of the platelet activation pathway have been developed. Clopidogrel, a new adenosine diphosphate receptor antagonist, is more effective than aspirin in reducing vascular events in patients with prior myocardial infarction, stroke, or established peripheral arterial disease. The glycoprotein IIb‐IIIa antagonists such as abciximab have proven effective in the setting of active arterial thrombosis and percutaneous revascularization, but their value in secondary prevention remains unknown. All patients with atherosclerosis should be treated with an antiplatelet drug. Current evidence suggests that either aspirin or clopidogrel are appropriate first‐line agents. There is urgent need for an analysis of the risk/benefit ratio in various populations and clinical settings to determine the most appropriate type and intensity of therapy for a given patient.
Impaired endothelial function in patients with rapidly stabilized unstable angina: Assessment by noninvasive brachial artery ultrasonography
Authors: Bereziuk Eulalio , Bolaño Alberto L. , Suarez Daniel H. , Kura Marta , Esper Ricardo J. , Vilariño Jorge , Cacharrón José L. , Machado Rogelio , Ingino Carlos A. , GarcGuiñaz Carlos A.
Published: February 2009

Background:Endothelial dysfunction may contribute to symptoms of instability in patients with acute coronary syndromes. High‐resolution external ultrasound assessment of the brachial artery responses allows noninvasive determination of endothelial function.

Hypothesis:This study was conducted to assess endothelial function in patients with unstable angina using a noninvasive technique.

Methods:We studied 189 patients who were subdivided into three groups. Group 1:60 apparently healthy subjects with no cardiovascular risk factors or symptoms of coronary artery disease; Group 2: 105 subjects with cardiovascular risk factors—arterial hypertension, hypercholesterolemia, cigarette smoking, diabetes, and obesity, but no evidence of coronary artery disease; and Group 3: 24 patients with unstable angina (chest pain at rest within the 24 h preceding study entry). All patients underwent pre‐ and postischemic brachial artery test evaluation with measurements of internal arterial diameters and blood flow.

Results:Results are expressed as percentage change from basal values. Subjects in Groups 1 and 2 showed a diameter increase of 19.1 and 11.9%, respectively, whereas patients in Group 3 showed a diameter change of 1.2% (p < 0.002 and < 0.0001, respectively). Calculated blood flow did not differ significantly in Groups 1 or 2 (74.4 and 56.4%), but was notably lower in Group 3 (18.4%, p<0.005 vs. Groups 1 and 2). In nine patients of Group 3, the brachial studies were repeated 4 weeks after symptom stabilization and showed values comparable with those in Group 2.

Conclusions:Patients with unstable angina showed endothelial dysfunction compared with control individuals. It is of interest that in patients whose symptoms were stabilized by medical therapy, endothelial function was restored 4 weeks after hospital discharge.