Jonathan Balkin

Incidence and significance of a positive troponin test in bacteremic patients without acute coronary syndrome.

BACKGROUNDnSince the introduction of troponin for the diagnosis of myocardial infarction, several studies have shown additional conditions in which troponin is elevated, including sepsis. The objective of this study was to determine the incidence of an elevated troponin in patients with bacteremia and its significance.nnnMETHODSnThis was a prospective, noninterventional study. Patients with a positive blood culture were included. Cardiac troponin I (cTnI) was determined within 4 days of blood culture. A repeat electrocardiogram was obtained in a sample of patients with elevated cTnI and in patients with a negative troponin test. Demographic, clinical, and microbiological data were obtained for all patients.nnnRESULTSnA total of 159 bacteremic patients were included. Positive cTnI was detected in 69 patients (43%). Elevated cTnI was associated with a number of underlying diseases, hospitalization ward, severity of the systemic inflammatory condition, and kidney function (P<.05-.001). A repeat electrocardiogram was performed in 39 patients with a positive cTnI and in 28 patients with a negative cTnI. Two of 39 patients (5%) in the positive cTnI group had ischemic changes and 2 patients (5%) had nonspecific changes, whereas only 1 patient (4%) with a negative cTnI had nonspecific changes. Bivariate analysis revealed a statistically significant association for positive cTnI and mortality; however, on multivariate analysis this was no longer significant.nnnCONCLUSIONnForty-three percent of bacteremic patients had an elevated cTnI. Risk factors for elevated cTnI were severity of the underlying infection, renal function, and underlying cardiac disease. Increased cTnI was found to be a dependent risk factor and a surrogate marker for death.

QT Interval in Patients with Unstable Angina and Non-Q Wave Myocardial Infarction

Background: Non‐Q wave mvocardial infarction (NQMI) and unstable angina (UAP) have similar clinical presentations and similar ST‐T changes on the electrocardiogram. The purpose of this study was to assess whether changes in QT interval might help differentiating between these entities.

Effect of caldaret on the incidence of severe left ventricular dysfunction in patients with ST-elevation myocardial infarction undergoing primary coronary intervention.

Primary percutaneous coronary intervention (PCI) decreases myocardial damage in patients with ST-elevation myocardial infarction (STEMI). Cellular reperfusion injury associated with calcium overload may limit myocardial salvage. We previously showed (CASTEMI trial) that caldaret (MCC-135), which modulates myocardial calcium handling when administered before PCI in patients with STEMI, did not change residual left ventricular (LV) function. The aim of this subanalysis was to examine whether caldaret decreases the incidence of LV dysfunction (LV ejection fraction <or=30%) in patients with STEMI undergoing primary PCI. Of 387 patients enrolled in the CASTEMI study, 239 had single-photon emission computed tomographic data on days 7 and 30 after the infarct. The incidence of LV dysfunction in patients receiving low- and high-dose caldaret was compared with placebo. At day 30 after the infarct, there was a significant decrease in the incidence of LV dysfunction in patients receiving low and high doses of caldaret versus placebo (8.0%, 6.9% vs 17.5%, p <0.05 for the 2 comparisons). This difference was more pronounced in patients with anterior wall MI and Thrombolysis In Myocardial Infarction grade 0/1 flow. In this group, 52% decrease in the incidence of LV dysfunction was observed already on day 7 after the infarct (p = 0.026). The incidence of an LV ejection fraction <or=30% was significantly decreased between day 7 and day 30 in patients treated with the 2 doses of caldaret and was unchanged in the placebo group. In conclusion, treatment with intravenous caldaret in patients with STEMI undergoing primary PCI is associated with a significant decrease in the incidence of severe LV dysfunction.

Transient Left Ventricular Apical Ballooning

Background: Transient left ventricular (LV) apical ballooning is characterized by acute onset of chest pain with reversible balloon-like LV motion abnormality, hypercontractile basal segments, ST segment elevation or T-wave inversion in anterior chest leads and mild cardiac enzyme rise in the absence of significant coronary disease. Methods: We describe 5 patients (4 females) with anteroapical ballooning who were hospitalized with acute myocardial infarction and showed ST segment elevation in anterior chest leads. Results: Echocardiogram demonstrated apical ballooning with normal or hypercontractile contraction of the basal segments. Four patients had severe mitral incompetence and one had mild incompetence. All patients had also systolic anterior motion and 4 had a significant LV outflow (LVOT) gradient. All patients underwent cardiac catheterization soon after admission showing non-significant narrowing of the coronary arteries. At discharge 4 patients had normal LV function and 1 was mildly impaired. Conclusions: LV apical ballooning is relatively rare. It should be suspected in older patients, mainly women, with severe mitral incompetence and LVOT gradient.

Reproducibility of measurements of coronary narrowings by videodensitometry: Unreliability of single view measurements

Computer-assisted videodensitometry has been shown to be a reliable and reproducible method of measuring absolute and relative coronary narrowings. Using a commercially available analyzer (Vanguard XR70) we confirmed the intra- and interobserver reproducibilities in 34 narrowings in 9 patients. Analyses were performed on normal area and diameter, stenotic area and diameter, percent area stenosis and percent diameter stenosis. For all 6 analyses, excellent intra- and interobserver correlations were found (r=0.93–0.98), with slopes close to 1 and intercepts close to zero. In a separate study of 16 lesions in 11 patients, each lesion was analysed in both the RAO and LAO planes. Correlation between the measurements was reasonable with r=0.76 for the stenotic area and r=0.75 for the absolute diameter stenosis. However, with suboptimal slopes (0.54 and 0.63 respectively), actual differences between measurements in the two planes were often unacceptably large.These data suggest that videodensitometry is a highly reproducible quantitative angiographic method; however, single view analyses are inadequate for comparitive studies.

Familial Membranous Subaortic Stenosis

Familial occurrence of membranous subaortic stenosis (MSS) is described in three families. The defect was found in 2 siblings in two of these families, and in 3 siblings of the third family. The importance of early diagnosis and treatment of MSS is emphasized. We suggest early evaluation of first-degree relatives of patients with MSS for the possibility of this defect.

Reproducibility of Measurements of Coronary Narrowings by Videodensitometry and by Digital Calipers

Computer-assisted videodensitometry has been shown to be a reliable and reproducible method of measuring absolute and relative coronary narrowings. Using a commercially available analyzer (Vanguard XR70) we confirmed intra- and interobserver reproducibilities in 34 narrowings in 9 patients. Analyses were performed on normal area and diameter, stenotic area and diameter, percent area stenosis and percent diameter stenosis. For all 6 analyses, excellent intra- and interobserver correlations were found (r = 0.93-0.98), with slopes close to 1 and intercepts close to zero. Caliper measurements (Mitutoyo Digimatic) of the same lesions by the same observers showed good inter- and intraobserver reproducibility for percent diameter stenosis (r = 0.90 and 0.86), with mean interobserver difference of 1.67 +/- (SD) 6.4% and intraobserver difference of 2.97 +/- (SD) 7.9%. However, less good correlations were found between caliper and videodensitometric measurements of percent diameter stenosis; r = 0.61 and 0.76 for the two observers. These data suggest that videodensitometry is a highly reproducible quantitative angiographic method, suitable for documenting changes in the severity of coronary artery lesions, both spontaneous or related to interventions. Caliper measurements do not provide the same degree of accuracy, but they have acceptable reproducibility in measuring diameter stenosis. As such, they are also suitable for assessing changes in severity of coronary artery lesions in individual patients.

Progression and regression of coronary artery disease in one year. Quantitative angiographic assessment in patients with stable angina pectoris.

The rate of progression of coronary artery stenoses (CAS) is not clear. Spontaneous regression may also occur.Seventy-one CAS in 25 patients who were enrolled in a study of the effects of chromium on CAS were analysed. Coronary angiography was performed in multiple views and patients randomised to chromium or placebo treatment. Videodensitometric quantitative analysis was performed using a Vanguard XR70 Analyzer. After 1 year all patients were recatheterised. Corresponding frames from identical views were analysed. CAS were assessed with the observers blinded to the initial study results. No differences were found between chromium or placebo and the results have been combined. There was no overall progression of CAS as assessed by % area stenosis (p=0.65), % diameter stenosis (p=0.19), stenotic area (p=0.87), or stenotic diameter (p=0.99). However, 20% of individual lesions progressed, while 10% regressed, and 70% remained the same.These changes must be taken into account in studies of interventions which may modify the course of coronary atherosclerosis, and if coronary by-pass surgery is to be performed with a 1 year delay after angiography.

Acquired Obstruction of the Ventricular Septal Defect in Tetralogy of Fallot

The interventricular septal defect in patients with tetralogy of Fallot is, in most cases, a nonrestrictive malalignment type of defect. Rare examples of a restrictive defect have been described. We report a case of tetralogy of Fallot with pulmonic atresia in which the interventricular septal defect was found to be nonrestrictive at birth. The obstruction of the defect developed gradually, until, at the age of 6 years, a gradient of 55 mm Hg across the defect was found at repeat cardiac catheterization. Echocardiography proved that the acquired obstruction was due to excessive tricuspid valve tissue, while Doppler studies suggested a similar gradient between the right ventricle and the ascending aorta. This rare case should alert the clinician to the possibility of an acquired obstruction of the ventricular septal defect, with suprasystemic right ventricular pressure, in cases of tetralogy of Fallot, even if an early study suggested a nonobstructive defect. The diagnosis of this situation is of importance because of the poor prognosis which it carries.

Buddy balloon for TAVI.

Percutaneous transfemoral aortic valve replacement is a new rapidly evolving technique that has made significant progress in recent years. The technology is however limitted and in some cases has resulted in failure to deliver the prosthetic valve. We describe a new technique using a buddy balloon, from the contralateral femoral artery, to assist in crossing the native aortic valve in those cases where extreme calcification and or tortuosity have caused the delivery system to hang up on the aortic wall. The technique is easily applied and facilitates the success of the procedure in cases which may otherwise have to be converted to open surgical aortic valve replacement.