F. Bartolomucci

Noninvasive detection of vascular dysfunction in alcoholic patients

Vasodilation is impaired in various conditions, such as hypercholesterolemia and tobacco use. We evaluated brachial artery flow-mediated vasodilation (FMD) after blood pressure (BP) cuff occlusion using high-resolution B-mode ultrasound in 20 alcoholics, without any coexisting conditions such as smoking, hypertension, or cholesterolemia, after a 3-month period of abstinence. They were compared with a control group of 20 alcohol-free healthy subjects. We measured the diameter of the brachial artery under baseline conditions, during reactive hyperemia (with increased flow causing endothelium-dependent dilatation), and after administration of sublingual glyceryl trinitrate (GTN), an endothelium-independent dilator. We performed an echocardiographic study (Esaote Au3) according to guidelines of the American Society of Echocardiography to assess left ventricular mass (LVM), wall thickness, systolic stress, and diastolic function changes. FMD (% diameter change) was significantly less in the alcoholic patients than in the controls (6.03+/-3.67 v 13.7+/-4.65; P < .05), whereas no difference was noted after GTN administration (13.7+/-7.97 v 16.0+/-5.12, P = NS). Echocardiographic study showed no differences between the study group for LVM, wall thickness, and systolic stress; diastolic function expressed as E/A ratio inversion was significantly impaired. These data demonstrate an impairment of endothelial-dependent vasodilatation in chronic alcohol abusers, which may contribute to the excess prevalence of cardiovascular diseases in these individuals.

Effect of alcohol consumption versus abstinence on 24-h blood pressure profile in normotensive alcoholic patients

The aim of this study was to evaluate 24-h ambulatory blood pressure monitoring in 15 male alcoholic normotensive subjects during alcohol consumption and following an abstinence phase and the effects of alcohol consumption compared with a period of 1 week of abstinence. The average 24-h BP was not different, but the diurnal pattern showed a fall in systolic BP early (06:00 to noon; P < .005) and late (18:00 to 22:00; P < .002) in the day during abstinence. BP variability was increased during the alcohol phase (P < .05). This study showed that 1 week of abstinence does not influence 24-h BP levels in normotensive subjects, but alters the diurnal pattern, characterized by a fall in systolic BP and increased BP variability.

Three-year results of repaired barlow mitral valves via right minithoracotomy versus median sternotomy in a randomized trial

Objectives: To clarify whether the results of repair of a complex mitral lesion (Barlow valve) at the intermediate-term follow-up are independent of the mode of surgical access [minithoracotomy vs. median sternotomy (MS)]. Methods: In a prospective randomized study of mitral repair for Barlow disease using either a minimally invasive (MI) approach or MS, we achieved an average follow-up of 3 years (echocardiography, physical examination and quality of life). Mitral repair was achieved with polytetrafluoroethylene chordal implantation for both leaflets. Results: Both groups included 80 patients. Mechanical ventilation time and intensive care unit and hospital stay were shorter in the MI group (p = 0.01, p = 0.013 and p = 0.02, respectively). During the follow-up, 5 patients in each group (6.25%) displayed mild mitral regurgitation, while 2 patients in each group (2.5%) developed recurrent regurgitation graded as at least moderate/severe. The rate of mitral reoperation was 2.5% in the MI group and 1.25% in the MS group (p = 0.9). The overall follow-up mortality was 3.75% in both the MI and the MS groups. Conclusions: The 3-year results of repair of Barlow valves were satisfactory irrespective of the approach used to repair the valve. The advantages of MI surgery can be achieved in patients with mitral Barlow disease without concerns over the durability of repair.

Impaired Endothelium Independent Vasodilation in Nonobstructive Hypertrophic Cardiomyopathy

BACKGROUND In patients with hypertrophic cardiomyopathy (HCM) an impaired microvascular function is reported not only in the hypertrophied septum but also in the nonhypertrophied left ventricular free wall as well as in forearm resistance vessels, thus suggesting a generalized alteration in vascular function. However, information on conduit artery involvement is still sparse and controversial. The aim of this study was to evaluate whether functional abnormalities are detectable in the arteries of HCM patients. METHODS In a group of newly diagnosed, previously untreated, patients with nonobstructive HCM, conduit artery endothelium dependent and independent vasodilation (EDV and NEDV, respectively) were assessed with high resolution ultrasound by measuring respectively flow-mediated vasodilation and response to sublingual nitroglycerine of the brachial artery. Normotensive subjects free of cardiovascular disease and risk factors and untreated hypertensive patients with left ventricular hypertrophy were studied as control groups. RESULTS Compared to normotensives, HCM patients showed significantly blunted NEDV (13 ± 6% vs. 23 ± 7%, P < 0.01), whereas EDV was not significantly different between the two groups (11 ± 4 for HCM vs. 13 ± 4% for normotensives, P = 0.25). In the hypertensive group, both NEDV and EDV were significantly decreased compared to normotensives (P = 0.01 and P < 0.01, respectively). CONCLUSIONS Patients with HCM show a reduced vasodilator response of systemic conduit arteries to nitroglycerine, suggesting a remodeling of vascular wall or smooth muscle cell dysfunction.

Coronary Flow: From Pathophysiology to Clinical Noninvasive Evaluation

Coronary artery disease is the leading cause of mortality in western countries. Myocardial contraction is indeed closely connected to coronary flow and oxygen delivery; the balance between oxygen supply and demand is a crucial determinant of the normal function of the heart. Acute impairment of this relationship due to coronary blood flow reduction results in a vicious cycle, where ischemia-induced contractile dysfunction causes hypotension and further myocardial ischemia.

A strange weakness: a case-report of dilated cardiomyopathy in a young patient with spontaneous coronary dissection

Introduction Atherosclerosis is the most common cause of coronary affections, but coronary dissection is certainly more insidious. This is the separation of the media apart from the other layers of the vessel wall, with or without intimal tear. Spontaneous coronary dissection is a rare event, especially in young men: only 150 cases were reported till 1986 and over 300 till date. The main consequence is an acute coronary occlusion with myocardial infarction and sudden death. Case report We report the case of a 28-year-old man, presented with a mild symptomatic spontaneous coronary dissection, consisting of a strange weakness, remained undetected until fortuitous medical analyses suggested the opportunity of further investigations. A clinical examination and an EKG showed the opportunity to perform a bidimensional echocardiogram at first, a low-dose dobutamine stress echocardiogram, then a regional myocardial perfusion and a non-invasive coronary flow reserve assessment. The patient has been properly and quickly screened and is now enlisted for cardiac transplantation. Conclusions In such cases the immediate identification and treatment of the affection can be crucial. In our experience the basic and advanced echocardiography allowed a sooner diagnosis than the usual proceeding based on coronarographic examination.