Domenico Maria Zardi

Human coronary atherosclerosis modulates cardiac natriuretic peptide release

UNLABELLED Natriuretic peptides (NPs) modulate vasodilatation and vascular remodelling. In human coronary explants, expression of NPs mRNA and their respective receptors is significantly more pronounced with advanced atherosclerotic lesions. AIMS We hypothesize that vascular atherosclerosis modulates NP release in vivo during progressive stages of coronary atherosclerosis. METHODS AND RESULTS NT-proANP (A) and NT-proBNP (B) were assessed on blood samples of 194 patients. Coronary atherosclerosis was assessed in all patients by angiography and in case of moderate stenosis by fractional flow reserve (FFR), a validated tool for detecting ischemia-inducing stenosis. Significant coronary stenosis was defined as a diameter stenosis (DS) >/=50% and/or positive FFR. Endothelial dysfunction was detected by cold pressure test (CPT) in a subgroup of 99 patients. Patients were divided into: (1) normal group (normal endothelial function, n=19); (2) endothelial dysfunction group (n=17); (3) moderate atherosclerotic group (at least one coronary stenosis <50%, n=86); (4) stenotic group (n=72). A and B were higher in patients with endothelial dysfunction (A: 2951 [1290-3920] fmol/ml; B: 156 [98-170] pg/ml), moderate atherosclerotic (A: 3868 [2250-5890] fmol/ml, p<0.05 vs. normal; B: 162 [84-283] pg/ml) and stenotic group (A: 3934 [2647-5525]; B: 227 [191-784] pg/ml; p<0.05 vs. normal) as compared with normal group (A: 2378 [970-2601] fmol/ml; B: 78 [40-136] pg/ml). During CPT, a mild NT-proANP increase was observed only in patients with endothelial dysfunction (Delta% vs. baseline: 17+/-6, p<0.05). NT-proBNP did not change after CPT in all groups. CONCLUSION Well defined stages of atherosclerosis are characterized by progressive increases in NT-proANP and NT-proBNP levels, beginning with endothelial dysfunction and progressively more pronounced with moderate and severe coronary atherosclerosis irrespective of the underlying myocardial disease.

Anomalous origin and aneurysm of the suprascapular artery: the first case observed.

A 45-year-old woman was referred to our department having suddenly developed, 9 months earlier, a pulsating mass on the right supraclavicular fossa and torticollis. Colour Doppler sonography and computed tomographic angiography showed the presence of an aneurysm (21 mm in diameter) of the suprascapular artery that had an anomalous origin from the subclavian artery. Thoracic outlet syndrome was excluded. After selective arteriography, the aneurysm of the suprascapular artery was successfully treated with ethylene-vinyl alcohol polymer (Onyx, MicroTherapeutics, Irvine, California, USA), a liquid embolic agent. The patient was discharged on the first postoperative day in good condition. Control colour Doppler sonography at 1 year confirmed the complete thrombosis of the aneurysm sac.

Diagnostic approach to neuropsychiatric lupus erythematosus: what should we do?

ABSTRACT Neuropsychiatric systemic lupus erythematosus is a diagnostic challenge due to the multifarious neurological and psychiatric manifestations that define it but, when suspected, diagnostic imaging can give a fundamental help. The advancements and variety of neuroimaging techniques allow us to perform more and more accurate evaluations of structure, perfusion, and metabolism of the brain and to detect cerebral and spinal lesions. Moreover, vascular districts of the neck and the brain, as well as the electrical brain and peripheral muscle activity may be accurately investigated, thus giving us a wide panoramic view. Although magnetic resonance is recognized as a fundamental neuroimaging technique to reach a correct diagnosis, the juxtaposition of other diagnostic techniques has improved the possibility to make diagnoses but has also increased the confusion about deciding which of them to use and when. Our aim was to combine the number of available techniques with the need to simplify the diagnostic path. Therefore, through the construction of an algorithm from an evidence based approach, we believe we are providing some added improvements to facilitate and expedite the diagnosis of NPSLE.

An ultrasound automated method for non-invasive assessment of carotid artery pulse wave velocity

To validate the clinical applicability and feasibility of an automated ultrasound (US) method in measuring the arterial stiffness of patients with chronic inflammatory rheumatic diseases, comparing automated measurements performed by a rheumatologist without experience in vascular sonography with those obtained by a sonographer experienced in vascular US, using a standardized manual method. Twenty subjects affected by different chronic inflammatory rheumatic disorders were consecutively recruited. For each patient, the arterial stiffness of both common carotids was manually calculated. Subsequently, the measure of the pulse wave velocity (PWV) was obtained using an US device called Radio Frequency - Quality Arterial Stiffness (RF-QAS), provided by the same US system (ie, My Lab 70 XVG, Esaote SpA, Genoa, Italy) equipped with a 4–13 MHz linear probe. The reliability comparison between the two US methods was calculated using the intraclass correlation coefficient (ICC). ICC between the values obtained with the two methods for calculating the arterial stiffness resulted 0.789. A significant positive correlation between the two methods was also established with Pearson’s (r=0.62, p<0.0001) and Spearman’s analysis (r=0.66, p=0.001). A significant performance comparison was seen using Bland-Altman plot. The acquisition of the arterial stiffness parameter with the automated method required about 2 min for each patient. Clinical applicability of this US automated method to assess PWV at common carotid level by a rheumatologist is reliable and feasible in comparison with a conventional manual method.

Viral cirrhosis with chronic right heart failure and cardiac liver sclerosis: a hypothesis on the differentiation between the two diseases through pulsed Doppler sonography examination

Chronic right heart failure determines cardiac liver sclerosis as a consequence of the hepatic venous congestion that is easily detectable with pulsed Doppler sonography measuring hepatic venous pulsatility. These Doppler parameters profoundly change on the basis of the causative agent of the liver sclerosis. In fact, on pulsed Doppler examination, we detected a flat waveform in hepatic veins of subjects with viral liver cirrhosis whereas we only observed biphasic waveforms in subjects with cardiac liver sclerosis. On the contrary, a pulsed Doppler sonography pattern in subjects with viral cirrhosis and associated chronic right heart failure is unknown. We suppose that splanchnic pulsed Doppler sonography has an important role both in differentiating cardiac liver sclerosis from viral cirrhosis with chronic right heart failure and in the follow-up of the seriousness of the right ventricular failure.

Cirrhotic Cardiomyopathy and Liver Transplantation

Cirrhotic cardiomyopathy is a clinical syndrome in patients with advanced liver cirrhosis characterized by a blunted contractile responsiveness to stress and/or altered diastolic relaxation with electrophysiological abnormalities, in the absence of known cardiac disease. The mechanisms underlying this syndrome are to be reconducted to toxic effects of endogenous mediators as well as an impaired myocardial receptor function. From a clinical standpoint cirrhotic cardiomyopathy is often latent (asymptomatic) for months to years and, when clinically evident, is characterized by symptoms of exercise intolerance, fatigue, and dyspnea that are difficult to differentiate from other conditions present in patients with advanced liver cirrhosis. Cirrhotic cardiomyopathy is therefore often undiagnosed. The acute onset or worsening of cardiac failure after liver transplantation has highlighted the importance of this syndrome in the post-transplant prognosis. Identification of patients with cirrhotic cardiomyopathy may help risk stratification of patients before and after liver transplantation. Cirrhotic cardiomyopathy is often associated with preserved left ventricular ejection fraction; therefore, the use of newer noninvasive diagnostic techniques (i.e., tissue Doppler, myocardial strain) is necessary to identify such patients. Treatment of heart failure in patients with cirrhotic cardiomyopathy before or after transplantation may lead to improved quality of life in patients prior to transplantation and may reduce complications in patient undergoing liver transplantation. Specific therapies for cirrhotic cardiomyopathy are however lacking. A deeper understanding of the mechanisms of the cardiomyopathy and testing for specific therapies is eagerly needed.

Portopulmonary hypertension and hepatorenal syndrome. Two faces of the same coin

Portopulmonary hypertension and hepatorenal syndrome are both severe local hypertensive complications of liver cirrhosis and portal hypertension. Both are characterized by vasoconstrictive manifestations regarding pulmonary and renal vascular network, respectively. This review addresses the mechanisms underlying the development of vasoconstriction that leads to local vascular hypertension in the lung and in the kidney with the result of organ dysfunction. Potential therapeutic options are available for the management of these two syndromes as a bridge for liver transplantation; clinical efficacy depends in part on the time and rapidity of intervention and in part on how serious the chain of events is that has triggered the entire vasoconstrictive process.

Rare left ventricular metastasis from uveal melanoma

A 60-year-old white woman was admitted to our hospital, October 2016 because of two episodes of hematemesis in the previous 48 h, intensification of fatigue and lack of appetite. A review of the patient’s history revealed that a stage IV right ocular melanoma had been diagnosed 7 years prior to admission. The patient underwent proton beam therapy and then first-line and second-line chemotherapy treatment. When the patient was admitted she was affected by multiple subcutaneous (Fig. 1A), pericardial (Fig. 1B, C), pulmonary and hepatic metastases. Subcutaneous metastases had been previously treated with electrochemotherapy. Blood analysis showed mild anemia (red blood cells 2.980.000 μL, hemoglobin 9.7 g/dL) and an increased inflammatory pattern (white blood cells 12540 μL procalcitonin 1.7 ng/mL, C reactive protein 10 mg/L) as observed in multiple metastasis [1]. Physical examination revealed pale skin color, increased liver consistency and volume; no other abnormalities were found, including cardiac auscultation. Electrocardiogram and hemogasanalysis were also normal. In order to rule out upper gastrointestinal bleeding, esophagogastroduodenoscopy was performed and showed no abnormalities. Given the suspicion of pulmonary embolism, due to advanced cancer and recurrent haemoptysis, we performed a trans-thoracic echocardiography that showed normal parameters (left ventricular diastolic and systolic diameter 44 mm and 29 mm, septal thickness 9 mm, posterior wall thickness 8 mm, ejection fraction 58%, left atrial area 14 cm, right atrial area 12 cm, right ventricular diastolic and systolic diameter 27 mm and 16 mm, TAPSE 18 mm) and there were no signs of right heart overload; unexpectedly, a pedunculated 15 × 13 × 14 mm mass was present, adherent to the endocardium, involving the lower third of both the interventricular septum and the left ventricle inferior wall (Fig. 1C, D). The mass was slightly hyperechoic and non-homogeneous with irregular margins (Fig. 1D). The color-Doppler did not show significant vascularization of the mass. No signs of patent foramen ovale were observed. The case was then discussed by a multidisciplinary team including oncologists and cardiac surgeons. Considering the evidence of multiple metastatic disease, the poor prognosis and thus the unfeasibility of any surgical and medical treatment of the patient, it was decided to stop any further diagnostic and/or therapeutical procedure and to continue palliative cure. The patient was then discharged 5 days after admission. Uveal melanoma is the most common primary intraocular malignancy; approximately 1500 cases are diagnosed in the United States each year, most commonly arising in the choroid followed by the ciliary body. The patient can be entirely asymptomatic and the tumour diagnosed only on routine ophthalmic screening [2]. The heart may be colonized by metastatic cells of uveal melanoma through the vascular system but often the diagnosis is missed over a lifetime [3]. It has been known since 1954 that the right side of the heart is more commonly involved by metastases, whereas only few of them have been reported in the left heart [3–5]. CLINICAL CARDIOLOGY

Effort angina in a patient with advanced coronary artery disease. Role played by coronary angiography, Ivus and cardiac CT: case report

Coronary angiography is considered to be the gold standard technique for assessing the severity of obstructive luminal narrowing; however, in a few circumstances it may be misleading. In these cases, cardiac computed tomography (CT) and intravascular ultrasound (IVUS) may help to give a correct interpretation.In this report, we describe the case of a 62-year-old man whose effort angina was first evaluated with coronary angiography, but whose severe stenosis of the right coronary artery was only observed on cardiac CT and IVUS. This additional diagnosis promptly resulted in a therapeutic approach with percutaneous transluminal coronary angioplasty (PTCA).