Martino Pepe

Th2-dependent cytokine release in patients treated with coronary angioplasty.

AimThe aim of this study is to investigate the T helper (Th)2-dependent release of interleukin(IL)-4 and IL-13 in patients with unstable angina treated with coronary angioplasty (PCI). MethodsThis study involved 48 consecutive patients with unstable angina who underwent PCI. Blood samples were taken before and 48 h after PCI to evaluate serum IL-4 and IL-13 levels. Coronary atherosclerosis was assessed in terms of the severity of the treated lesions and the presence of multivessel disease, and compared with IL release. ResultsBefore and after PCI, serum IL-4 levels were, respectively, 53.1±110.7 and 35.1±16.9 pg/ml (P not significant), and serum IL-13 levels 6.7±3.7 and 6.0±2.9 pg/ml (P<0.05). A correlation was present between the severity of the treated coronary lesions and serum IL-13 levels (r 0.36; P<0.05). The patients with multivessel coronary artery disease had a higher periprocedure ratio of IL-4 than those with single-vessel coronary artery disease (1.46±0.76 vs. 0.89±0.34, P<0.001). ConclusionA significant decrease was observed in Th2-dependent IL concentrations after PCI; increased Th2-dependent IL levels before PCI seem to correlate with the severity of coronary atherosclerosis.

Sudden cardiac death secondary to demonstrated reperfusion ventricular fibrillation in a woman with Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a left ventricle cardiomyopathy characterized by a reversible dyskinesia responsible for the typical apical ballooning aspect. The disease is considered benignant with a full recovery within a few weeks. We present the case of a 52-year-old woman who presented with angina diagnosed with Takotsubo cardiomyopathy on the basis of both noninvasive (electrocardiography, echocardiography) and invasive (angiography) exams. At discharge, a Holter monitor was fitted to the patient. During the recording the patient faced sudden cardiac death. The analysis of the Holter traces allowed some speculations on the mechanism of this unexpected arrhythmic death. The cause of the fatal ventricular fibrillation appears to be the fast reperfusion following a short occlusion of an epicardial coronary artery. This case highlights the epicardial vasospasm as an important pathogenic mechanism of the syndrome and the possible usefulness of diagnostic tests able to elicit the spasm susceptibility and guide a more targeted pharmacological therapy. Some considerations are also possible on the cellular processes linking the rapid reperfusion and the arrhythmias onset.

A Striking Coronary Artery Pattern in a Grown-Up Congenital Heart Disease Patient

Left ventricular noncompaction (LVNC) is a myocardial disorder probably due to the arrest of normal embryogenesis of the left ventricle. It could be isolated or associated with other extracardiac and cardiac abnormalities, including coronary artery anomalies. Despite the continuous improvement of imaging resolution quality, this cardiomyopathy still remains frequently misdiagnosed, especially if associated with other heart diseases. We report a case of LVNC association with both malposition of the great arteries and a very original coronary artery pattern.

How to Approach a Spontaneous Coronary Artery Dissection: An Up-To-Date

Spontaneous coronary artery dissection (SCAD) is a separation of the coronary wall layers, not related to trauma, medical procedures or atherosclerosis. The dissection causes the blood entry in the vascular wall with the consequent formation of a false lumen and intramural hematoma (IMH). Two pathogenetic mechanisms have been proposed to explain SCAD: a “primary” rupture of coronary endothelium or the rupture of the “vasa vasorum”. Clinical presentation and severity of manifestations are variable, ranging from complete absence of symptoms to acute coronary syndrome (ACS), cardiogenic shock, cardiac arrest or sudden cardiac death. Despite coronary angiography is the first-line examination, by supplying two-dimensional images of the lumen, it does not always allow an incontrovertible diagnosis of SCAD. New intravascular imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS), have been recently introduced and may be extremely helpful in assessing the coronary wall integrity, thus improving coronary angiography diagnostic accuracy. Because of the lack of large randomized trials comparing different strategies, the optimal treatment of SCAD is still controversial. The first-line approach is conservative and based on medical therapy. Nevertheless, in particular situations an invasive approach is necessary. In the last years, several new strategies have improved the way to perform percutaneous coronary interventions (PCI), such as new generation drug eluting stents (DES), bio-resorbable scaffolds (BRS), sirolimus self-expandable stent (SES), drug eluting balloons (DEB), and cutting balloon. Cardiac artery bypass graft (CABG) is an even more invasive method to restore coronary flow and should be considered in urgent/emergent settings when PCI is not feasible or has failed. Cause the therapeutic approach of SCAD can be substantially different from that of atherosclerotic coronary artery disease, an accurate diagnosis is crucial to set up the best treatment strategy.

Aortic coarctation: guidelines mismatch across the ocean.

Pseudocoarctation is a rare congenital anomaly characterized by aorta elongation and kinking, without significant obstruction. We report the case of an elderly patient with history of congestive heart failure (CHF) and aortic regurgitation (AR) who was referred for progressive exertional dyspnoea. After multimodal imaging evaluation, aortic coarctation with significant trans-stenosis gradient but mild luminal narrowing was diagnosed; this borderline patient was not addressed to repair, according to ESC guidelines and in spite of AHA ones. He rather met the criteria for pseudocoarctation diagnosis. An integration of functional and anatomical data is essential for a reliable diagnostic process in similar cases.

Role of plasma glucose level on myocardial perfusion in ST-segment elevation myocardial infarction patients

AIMS Hyperglycemia is frequent in patients with ST elevation myocardial infarction (STEMI) and is associated with adverse outcome. Aim of our study was to evaluate the correlation between admission plasma glucose level (PGL) and coronary arteries flow velocity. METHODS We enrolled 149 STEMI patients successfully treated with primary percutaneous coronary intervention (pPCI). The study population was divided into two groups based on PGL (< or >140 mg/dl) and on history of diabetes, and the groups compared in terms of corrected TIMI frame count (cTFC). RESULTS Hyperglycemic patients had a significantly higher cTFC in both the culprit (p < 0.0001) and non-culprit vessel (p: 0.0002); diabetes history impairs as well cTFC of the culprit (p < 0.0001) and non-culprit vessel (p: 0.0001). Within the subpopulation of diabetic patients hyperglycemic ones showed higher cTFC in both the culprit (p 0.0013) and non-culprit vessel (p: 0.0006). Moreover in the whole population cTFC values of both arteries increase linearly with the increment of admission PGL. CONCLUSIONS Admission PGL affects coronary flow of both culprit and non-culprit vessel. The impairment of coronary flow is also demonstrated in known diabetic patients, suggesting to consider hyperglycemia an additional risk factor. We finally demonstrated for the first time a positive linear relationship between PGL and cTFC.

Prime time for the sweet spot in timing of coronary invasive approach in patients with non-ST elevation myocardial infarction

Acute coronary syndromes (ACS) continue to represent a major cause of morbidity and mortality worldwide. In the past decade data from the United States and Europe reported decreased incidence of ST-elevation myocardial infarction (STE-ACS) with an increase in non-ST-elevation myocardial infarction (NSTE-ACS) (1-3). As compared to STE-ACS patients, during initial admission, NSTE-ACS patients are at lower risk for death, but over time death rates become comparable with a trend towards increased mortality in the latter group (4). NSTE-ACS therefore constitutes a challenge in cardiology.

Massive stent thrombosis during active ulcerative colitis: the tricky balance between manifest hemorrhagic and concealed thrombotic risk

Inflammatory bowel diseases have been recognized as predisposing factors to atherosclerosis and thrombotic events, involving both the venous and the arterial circulatory systems. We report the case of a 70-year-old man who presented with ST elevation myocardial infarction during the active phase of ulcerative colitis (UC). Because of the ongoing hematochezia, after successful revascularization of the culprit vessel, the patient was medicated with Clopidogrel, in place of one of the more powerful new oral P2Y12 inhibitors that currently represent the gold standard therapy. Few days later a second elective percutaneous coronary intervention (PCI) on a non-culprit vessel ensued in a life-threatening early massive stent thrombosis involving the left main. During and after emergency PCI antiplatelet therapy was upgraded to Abciximab and Ticagrelor; this therapy proved successful in handling the massive stent thrombosis in the absence of severe bleeding complications. This case is unique and paradigmatic of the complex management of patients with coexisting active UC and acute coronary syndromes; it demonstrates as in this setting the balance between hemorrhagic and ischemic risk is labile and tricky to assess.

Time-dependent benefits of pre-treatment with new oral P2Y12-inhibitors in patients addressed to primary PCI for acute ST-elevation myocardial infarction

The aim of this observational study was to determine the benefits of the novel, orally delivered P2Y12‐inhibitors (Is) in terms of angiographic endpoints and in relation to the time of the loading dose (LD) administration.

Fractional flow reserve and intravascular scan as part of the coronary fistulas diagnostic process: Future perspectives

Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy Department of Cardiology, General Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany Department of Cardiology, Hospital “Santa Maria”, GVM Care and Research, Bari, Italy