Giovanni Gregorio

Chronobiological Patterns of Onset of Tako-Tsubo Cardiomyopathy: A Multicenter Italian Study

To the Editor: Several cardiovascular events, including acute myocardial infarction (AMI), show well-defined temporal patterns in their occurrence throughout the year and the day ([1,2][1]). Tako-Tsubo cardiomyopathy (TTC), also called “stress cardiomyopathy” or “transient left ventricular

Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy.

We report a case of transient tako-tsubo cardiomyopathy characterized by an unusual trigger in a woman victim of near-drowning syndrome. After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. Electrocardiogram changes and apical contraction abnormalities were reversed within 1 month. In conclusion, we hypothesize that hypoxemia related to near-drowning syndrome could have induced transient myocardial dysfunction mediated by a sympathetic nerve activation.

Right Ventricular Involvement and Pulmonary Hypertension in an Elderly Woman With Tako-Tsubo Cardiomyopathy

We describe a case of tako-tsubo cardiomyopathy in an elderly woman with a permanent pacemaker admitted to the ED with chest pain and dyspnea. Coronary angiography revealed normal coronary arteries. Typical left ventricular apical ballooning was demonstrated on contrast ventriculography. Left and right ventricular ballooning with pulmonary artery systolic hypertension was detected by transthoracic echocardiography. Velocity vector imaging and strain analysis showed a typical pattern of regional myocardial apical right ventricular contraction characterized by paradoxical positive longitudinal systolic strain. Biventricular involvement was associated with hemodynamic instability, signs of pulmonary vascular congestion, and bilateral basal pleural effusion. The patients clinical condition gradually improved, and she was discharged after prolonged hospitalization. Predischarge echocardiography showed substantial recovery of left and right systolic function along with normalization of pulmonary artery systolic pressure. Right ventricular function should be carefully evaluated in patients with tako-tsubo cardiomyopathy, especially in the acute phase.

SUMMER PREFERENCE IN THE OCCURRENCE OF TAKOTSUBO CARDIOMYOPATHY IS INDEPENDENT OF AGE

to this medical specialty at the European level. Unfortunately, Romania, although included in this study, did not provide information relating to geriatric education. The aging of the population represents a general characteristic at the European level; consequently, this demographic phenomenon also affects Romania, which has always geographically been a European country and a member of the European Union since January 2007. Since 1989, Romania’s population has been decreasing, which, in association with the decrease in birth rate and the increase in life expectancy, has aggravated the process of demographic aging. The proportion of elderly people is higher than that of young people, and the number of the adult population has decreased, whereas its proportion has increased. Although the influencing of the demographic process represents a true political and economic challenge, which is highly time and resource consuming, the improvement of medical services for the elderly population is a constant concern in Romania. In support of this affirmation, as head of the Department of Geriatrics, I will answer the questionnaire used in the methodology of the study EuropeWide Survey of Teaching in Geriatric Medicine.

Giant Left Atrial Myxoma: An Unusual Cause of Acute Pulmonary Edema

We report a case of a huge left atrial myxoma with an unusual clinical presentation characterized by acute pulmonary edema. The possible pathophysiologic mechanism has been discussed.

Transcranial Doppler ultrasound: Physical principles and principal applications in Neurocritical care unit

Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.

Isolated left cor triatriatum: a rare cause of effort dyspnoea in the adult.

Left cor triatriatum is a congenital heart disease characterized by an intra-atrial membrane determining obstruction and pressure gradient. We report an unusual case of cor triatriatum in a nonprofessional athlete presenting with effort dyspnoea. Although frequently diagnosed in the infant, it may also be a rare cause of effort dyspnoea in the adult.

Surgical treatment of impending paradoxical embolization associated with pulmonary embolism in a patient with heterozygosis of factor V Leiden.

We report an unusual case of impending paradoxical embolization in a 69-year-old woman heterozygote carrier of factor V Leiden mutation. The patient presented to the emergency room with the clinical scenario of massive pulmonary embolism. Serial echocardiographic examinations revealed a large thrombus in the right atrium floating via a patent foramen ovale into the left atrium. Anticoagulation therapy was started. After 72 h, due to the unresolved thrombus, the patient underwent surgical treatment consisting of complete excision of the thrombus, closure of the foramen ovale, and pulmonary embolectomy. No in-hospital complications were noted. At 1-year follow-up, the patient is doing well on long-term anticoagulation treatment free of thromboembolic events.

Intrahisian Conduction Disease and Junctional Ectopic Tachycardia

Junctional ectopic tachycardia (JET) is an uncommon arrhythmia that mainly affects pediatric patients. However, its clinical presentation may rarely occur in adulthood. Owing to its incessant nature, limited responsiveness to antiarrhythmic agents and poor prognosis, catheter ablation of the junctional focus is often required, even though this may be accompanied by the occurrence of complete atrioventricular block. We report the case of a 68‐year‐old man with episodes of sustained ventricular tachycardia and repetitive JET whose initiation was often anticipated by a sudden intrahisian conduction delay in the immediately preceding sinus beats.

Clinical value of echocardiographic assessment of coronary flow reserve after left anterior descending coronary artery stenting in an unselected population

Background Transthoracic Doppler echocardiography is a valuable tool to measure coronary flow reserve (CFR) and detect in-stent restenosis (ISR) after percutaneous coronary angioplasty in selected series of patients. Objectives To assess the usefulness of coronary flow reserve measured by echocardiography in detecting significant (≥70%) ISR of the left anterior descending coronary artery in a large unselected population. Methods Two hundred and twenty-three patients (age 61 ± 10 years; 168 men) treated with left anterior descending stenting underwent CFR measurement by transthoracic Doppler echocardiography and venous adenosine infusion 24–72 h before control coronary angiography. Coronary-active drugs were continued, and patients with multiple risk factors and old anterior–apical myocardial infarction were included. Results Significant ISR occurred in 56 patients (25%). Patients with ISR had higher basal coronary flow velocity (27 ± 10 cm/s vs. 24 ± 7 cm/s; P < 0.002) and lower CFR (1.5 ± 0.5 vs. 2.7 ± 0.6; P < 0.0001) than those without ISR. A linear relation was found between ISR and CFR (r = −0.73; P < 0.0001) and remained significant after adjustment for blood pressure and heart rate (r = −0.74; P < 0.0001). A CFR less than two identified significant ISR (sensitivity 88%, specificity 88%, area under the curve = 0.943; P < 0.001). In a multivariate model of CFR prediction, myocardial infarction and heart rate were slightly contributory (ß = −0.19, P < 0.01; ß = −0.16, P < 0.03, respectively), whereas ISR had a large influence (ß = −0.66; P < 0.0001). The inverse correlation between ISR and CFR persisted in patients with myocardial infarction (r = −0.64; P < 0.0001) and in those treated with β-blockers (r = −0. 71; P < 0.0001). Conclusion Echocardiographic measurement of CFR detects significant left anterior descending ISR in unselected patients with multiple risk factors, old anterior–apical myocardial infarction, and taking β-blockers.