Nicola Locuratolo

Functional and structural abnormalities in patients with dilated cardiomyopathy

Passive diastolic properties of the left ventricle were determined in 10 control subjects and 12 patients with dilated cardiomyopathy. Simultaneous left ventricular angiography and high fidelity pressure measurements were performed in all patients. Left ventricular chamber stiffness was calculated from left ventricular pressure-volume and myocardial stiffness from left ventricular stress-strain relations with use of a viscoelastic model. Patients with dilated cardiomyopathy were classified into two groups according to the diastolic constant of myocardial stiffness (beta). Group 1 consisted of seven patients with a normal constant of myocardial stiffness less than or equal to 9.6 (normal range 2.2 to 9.6) and group 2 of 5 patients with a beta greater than 9.6. Structural abnormalities (percent interstitial fibrosis, fibrous content) in patients with dilated cardiomyopathy were assessed by morphometry from right ventricular endomyocardial biopsies. Heart rate was similar in the three groups. Left ventricular end-diastolic pressure was significantly greater in patients with cardiomyopathy (18 mm Hg in group 1 and 22 mm Hg in group 2) than in the control patients (10 mm Hg). Left ventricular ejection fraction was significantly lower in groups 1 (37%) and 2 (36%) than in the control patients (66%). Left ventricular muscle mass index was significantly increased in both groups with cardiomyopathy. The constant of chamber stiffness (beta*) was slightly although not significantly greater in groups 1 and 2 (0.58 and 0.58, respectively) than in the control group (0.35). The constant of myocardial stiffness beta was normal in group 1 (7.0; control group 6.9, p = NS) but was significantly increased in group 2 (23.5). Interstitial fibrosis was 19% in group 1 and 43% (p less than 0.001) in group 2 (normal less than or equal to 10%). There was an exponential relation between both diastolic constant of myocardial stiffness (beta) and interstitial fibrosis (IF) (r = 0.95; p less than 0.001) and beta and fibrous content divided by end-diastolic volume index (r = 0.93; p less than 0.001). It is concluded that myocardial stiffness can be normal in patients with dilated cardiomyopathy despite severely depressed systolic function. Structural alterations of the myocardium with increased amounts of fibrous tissues are probably responsible for the observed changes in passive elastic properties of the myocardium in patients with dilated cardiomyopathy. The constant of myocardial stiffness (beta) helps to identify patients with severe structural alterations (group 2), representing possibly a more advanced stage of the disease.

Hemodynamic study of intravenous propionyl-L-carnitine in patients with ischemic heart disease and normal left ventricular function

SummaryPropionyl-L-carnitine was given intravenously to ten patients with chronic ischemic heart disease who had normal left ventricular function and had not had a previous myocardial infarction. Subsequently, pulmonary and systemic circulation, left ventricular function, and the relationship between the ventricle and afterload were evaluated. This drug, at a dose of 15 mg/kg, improves ventricular function by easing the load and by enhancing cardiac efficiency. The ejection impedance is reduced with a consequent increase in stroke volume as a result of a) a decrease in systemic and pulmonary resistance and b) an increase in arterial compliance. Arterial pressure is maintained due to an increase in total external heart power. Since the tension time index shows a proportionally smaller increase in the energy requirement, it follows that cardiac efficiency has been improved and ventricle-after load matching is optimal. These results suggest but do not prove that propionyl-L-carnitine exhibits a positive inotropic property.

Biventricular thrombosis in biventricular stress(takotsubo)-cardiomyopathy

Endo-ventricular thrombosis represents a possible clinical complication of stress(takotsubo)-cardiomyopathy (SC). Depressed ventricular systolic ventricular function, localized left ventricular (LV) dyskinesis, but also an increased pro-thrombotic state induced by catecholamine surge may facilitate the occurrence of endovascular thrombosis in SC. SC, however, may also present as right ventricular (RV) dysfunction or even as biventricular ballooning. Ventricular thrombosis may therefore theoretically occur in either ventricles or both. We report the case of an 88-year old woman, with vascular dementia and depression, admitted for abdominal pain, diarrhea, and rectal bleeding. Unexpectedly, electrocardiogram showed induced QT-prolongation with diffuse negative T-waves, while echocardiogram severe LV dysfunction (ejection fraction 35%), but also RV dysfunction and biventricular thrombosis. The diagnosis was therefore biventricular SC complicated by biventricular thrombosis; LV recovered after 10 days. When SC presents with a biventricular involvement, a careful assessment of either ventricular cavities should be therefore recommended to exclude the presence of (bi)ventricular thrombosis. It remains unresolved whether biventricular SC may represent a condition at higher risk of ventricular thrombosis.

One-year clinical outcome of biodegradable polymer sirolimus-eluting stent in all-comers population. Insight from the ULISSE registry (ULtimaster Italian multicenter all comerS Stent rEgistry)

BACKGROUND This study was designed to confirm in a large population of unselected patients the promising results of Ultimaster® biodegradable polymer sirolimus-eluting stent (BP-SES) already shown in previous trial. METHODS ULISSE is an observational, multicenter, national registry evaluating all patients undergoing PCI with the Ultimaster® BP-SES. Incidence of 1-year TLF (cardiac death or target vessel MI or clinically indicated TLR) was the primary endpoint. Pre-specified subgroup analysis was performed for diabetic patients and for those with lesion longer than 25 mm, bifurcation and CTO lesions. RESULTS 1660 patients were enrolled in 9 Italian cardiology centers, 82% were males, mean age of 68 ± 10 years, and 29% were diabetics. Overall 2422 lesions were treated, 65% type B2/C lesions, 7% CTOs, 17% bifurcations and 38% long lesions. The incidence of 1-year TLF was 5%, with 3.2% of clinically indicated TLR. TLF occurred in 8% of the patients with diabetes mellitus, and 7% in bifurcation, 6.7% in CTO and 6.2% in long lesions. Definite overall ST was 0.9%, and 1.2% in patients treated for type B2/C lesions. Multivariate logistic regression analysis identified stenting on unprotected LMT (OR = 4.80), stenting on ISR lesion (OR = 3.19) and need for rotational atherectomy (OR = 6.24) as the strongest independent predictors of TLF. CONCLUSIONS The results of this national all-comers registry show that the Ultimaster® BP-SES real-world performance was comparable with that observed in the clinical trial, with low rate of primary endpoint and TLR. Long term follow-up will be necessary to prove the theoretical advantage of the BP-SES over time.

ST-depression in right precordial leads with inferior STEMI and occluded right coronary artery: intertwined anatomy and ischemic areas

Right coronary artery (RCA) occlusion in inferior acute myocardial infarction is usually heralded by ST-elevation both in inferior and in right precordial leads. We report the case of a 68-year-old male, who presented marked ST-elevation in inferior leads, mirrored by ST-depression in anterior-septal and lateral leads. Right precordial lead electrocardiogram unexpectedly showed ST-depression V1R–V5R leads. Coronary angiography showed mid-left anterior descending (LAD) coronary near-complete occlusion with distal wrapping LAD. Left circumflex artery was not occluded, while RCA was occluded mid tract. The patient was treated with coronary angioplasty on RCA and LAD. Absence of ST-elevation in right precordial leads may be presumably explained by the presence of a large ischemic area distal to mid-LAD near-occlusive stenosis and of a long-wrapping LAD. Complex coronary anatomy and intertwined ischemic areas may underlie apparently discording electrocardiograms.

Kounis syndrome following canned tuna fish ingestion

Kounis syndrome (KS) is a complex of cardiovascular symptoms and signs following either allergy or hypersensitivity and anaphylactic or anaphylactoid insults. We report the case of 57-year-old man, with hypertension and history of allergy, referred for facial rash and palpitations appeared after consumption of canned tuna fish. Suddenly, the patient collapsed: electrocardiogram showed ST-elevation in inferior leads. The patient was transferred from the spoke emergency room for coronary angio, which did not show any sign of coronary atherosclerosis. A transient coronary spasm was therefore hypothesized and the final diagnosis was KS. To the best of our knowledge, this is one of the first cases of KS following the ingestion of tuna fish. KS secondary to food allergy has also been reported, and shellfish ingestion has been considered as one of the most active KS inducer foods. Canned tuna fish too is well known as an allergy inducer. Tuna fish allergy should be considered, however, within the context of scombroid food poisoning, also called histamine fish poisoning. Fish with high levels of free histidine, the enzyme substrate converted to histamine by bacterial histidine decarboxylase, are those most often implicated in scombroid poisoning. Inflammatory mediators such as histamine constitute the pathophysiologic basis of Kounis hypersensitivity-associated acute coronary syndrome. Patients with coronary risk factors, allergic reaction after food ingestion, and suspected scombroid poisoning should be therefore carefully monitored for a prompt diagnosis of possible coronary complications.

TCT-265 One-year Outcome of Polymer-free Amphilimus-eluting Stent versus Biodegradable Polymer Biolimus-eluting Stent in Diabetes Mellitus Patients. Propensity-Matched Analysis of the ASTUTE (AmphilimuS iTalian mUlticenTre rEgistry) and INSPIRE-1 (Italian Nobori Stent ProspectIve REgistry-1) Registries.

Patients with diabetes mellitus (DM) remain at higher risk for stent restenosis and adverse cardiovascular events, even in the drug-eluting stent era. The polymer free (PF) Amphilimus-eluting stent (AES) has shown promising preliminary results in patients with DM. The aim of this study was to