Paolo Cattaneo

Acute superior vena cava syndrome after insertion of implantable cardioverter defibrillator

We describe a rare case of superior vena cava syndrome that occurred a few hours after insertion of an implantable cardioverter defibrillator through the right subclavian vein in a patient with previous dual chamber DDD pacemaker. The patient was successfully treated with anticoagulant therapy showing a fast clinical and instrumental improvement.

Tako-tsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection.

Tako-tsubo cardiomyopathy is a form of reversible left ventricular dysfunction, with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. The precise clinical features and etiologic basis of this syndrome remain unclear, although an association with emotional or stressful triggers has been recognized. We describe the first case of this syndrome complicated with a ventricular septal perforation and dissection.

Imbalance between pro-angiogenic and anti-angiogenic factors in rheumatic and mixomatous mitral valves

BACKGROUND A balance between angiogenic and anti-angiogenic factors is critical in tissue development, tissue repair and homeostasis. Aberrant angiogenesis has been implicated in several pathologic conditions, including valvular heart disease. The aim of this study was to ascertain the pathogenetic role of angiogenesis in rheumatic and mixomatous mitral valve diseases. METHODS Leaflets from mixomatous (n=20) and rheumatic (n=20) mitral valves removed from surgical patients, and normal mitral valve (n=6) obtained at autopsy were collected. Immunohistochemical studies were performed on sequential valve sections, evaluating CD31, CD34, α smooth muscle actin (α-SMA), vascular endothelial growth factor (VEGF), VEGF receptor-1 (VEGFR1), VEGF receptor-2 (VEGFR-2), and chondromodulin-I (Chm-I). RESULTS Immunohistochemistry revealed significant differences among groups in CD31 (p=0.001), CD34 (p<0.001), α-SMA (p<0.001), VEGF (p<0.001), VEGFR1 (p=0.007), VEGFR2 (p=0.011), and Chm-I (p<0.001) expressions. Rheumatic valves demonstrated a severe up-regulation and down-regulation in pro-angiogenic and anti-angiogenic factors, respectively, compared with mixomatous and normal mitral valves. On the contrary, mixomatous valves showed a significant up-regulation of anti-angiogenic factors with respect to rheumatic and normal valves. CONCLUSIONS These findings provide evidence that an imbalance between pro-angiogenic and anti-angiogenic factors is implicated in mitral valve disease. Pro-angiogenic factors are up-regulated in rheumatic disease, while anti-angiogenic ones in mixomatous mitral valves.

Arrhythmic Risk Evaluation during Exercise at High Altitude in Healthy Subjects: Role of Microvolt T‐Wave Alternans

Background: Altitude‐induced sympathetic hyperactivity can elicit rhythm disturbances in healthy subjects, in particular during exercise.

The embolic storm : dramatic peripheral complications of left ventricular thrombosis after myocardial infarction

Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.

[Major epidemiological changes and clinical variables in patients undergoing a program of heart rehabilitation after cardiac surgery - MEPHISTOPHELES].

BACKGROUND Recent observational studies show an increase of more complex and critically ill patients referred to Italian cardiac rehabilitation (CR) departments; the exact mechanisms underlying this phenomenon, however, have not been clearly identified. The aim of our study was to evaluate the epidemiological and clinical changes that occurred over the last decade in patients hospitalized in CR departments with high admittance rates. METHODS We have retrospectively evaluated all patients admitted between 2002 and 2009 to our division of CR (n = 3340, 1155 female, mean age 66.4 ± 11 years) after recent cardiac surgery. The study population was divided into two homogeneous groups: the four-year period 2002-2005, group A (n = 1614, 540 female, mean age 66.1 ± 10 years) and the four-year period 2006-2009, group B (n = 1726, 615 female, mean age 67.4 ± 11 years). Data were compared using specific indicators of clinical complexity. RESULTS Patients aged >75 years were more in group B compared to A (26.3 vs 19.8%, p<0.0001), as well as patients with recent complex surgical interventions, such as combined coronary artery bypass grafting and heart valve surgery (16.4 vs 10.2%, p<0.0001). An increased incidence of cardiovascular death (1.4 vs 0.6%, p=0.02), acute coronary syndrome (1.5 vs 0.7%, p=0.02) and persistent atrial fibrillation/flutter (13.5 vs 7.1%, p<0.0001) was observed in group B, as well as an increased prevalence of systolic heart failure (18.3 vs 9.0%, p<0.0001). Similarly, the incidence of acute respiratory failure episodes (1.0 vs 0.4%, p=0.05), the prevalence of patients admitted with a tracheostomy tube (2.6 vs 0.2%, p<0.0001) and the incidence of acute renal failure (1.1 vs 0.5%, p=0.05) were significantly increased in group B. Postoperative infections and surgical wound complications were 4-fold higher in group B (13.9 vs 3.1%, p<0.0001, and 12.8 vs 2.3%, p<0.0001, respectively). Compared to group A, patients of group B showed a significantly lower physical performance, as expressed by the Rivermead motility index (3.8 ± 1.1 vs 5.2 ± 0.8, p<0.001); moreover, the number of subjects able to perform an incremental training program was significantly lower in group B than group A (14.8 vs 60.6%, p<0.0001). Mean hospital stay was longer in group B than group A (25.4 ± 13 vs 22.1 ± 9 days, p<0.001). CONCLUSIONS Our study, by collecting data from a CR division in northern Italy with high admittance rates, demonstrates a dramatic increase in clinical complexity over the last few years. This points to the need for new expertise and major resources to be allocated to CR departments.

Ejection fraction/velocity ratio identifies prosthesis-patient mismatches in patients with aortic bioprosthetic valves and left ventricular dysfunction.

Objectives. Recently, a new echocardiographic nonflow corrected index (ejection fraction/velocity ratio [EFVR] = percent left ventricular ejection fraction [EF]/maximum aortic gradient) has been introduced and has shown excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bio‐prostheses. The objective of this study was to assess the utility of the EFVR to quantify the indexed EOA in patients with an aortic bioprosthesis and left ventricular dysfunction considering an indexed EOA value of 0.85 cm2/m2 or less to be indicative of a prosthesis‐patient mismatch (PPM), defined as an EOA of the inserted prosthetic valve of less than that of the normal human valve. Methods. We studied 100 patients (62 men and 38 women; mean age ± SD, 71 ± 8.6 years) with an aortic bioprosthesis and left ventricular dysfunction (EF ≤49%), and we evaluated the indexed EOA by both the continuity equation (CE) and EFVR. Results. We found a significant linear correlation between the CE and EFVR (r = 0.85; P < .0001) and good agreement between the two methods in identifying patients with an indexed EOA of 0.85 cm2/m2 or less; the correlation began to become nonlinear for patients with an indexed EOA of greater than 1.2 cm2/m2, which was not clinically relevant. Notably, all 11 patients with a discrepancy between the indexed EOA and EFVR (ie, EFVR ≤1.0 and indexed EOA >0.85 cm2/m2) also showed an indexed EOA of greater than 0.85 but less than or equal to 1.0 cm2/m2 (meaning the presence of a mild PPM). Conclusions. The EFVR can be considered a reliable echocardiographic alternative to the CE, especially in conditions in which that is technically difficult, allowing identification of a PPM (indexed EOA ≤0.85 cm2/m2) with excellent sensitivity and specificity.

Tako-tsubo cardiomyopathy or aborted myocardial infarction?

We read with great interest the recent article by Eitel et al. 1 regarding the role of contrast- enhanced magnetic resonance imaging (MRI) in the differential diagnosis of suspected apical ballooning syndrome (ABS). The authors studied 59 consecutive patients with diagnosis of acute coronary syndrome, normal coronary arteries, and classical apical ballooning on left ventriculography; ABS was diagnosed by MRI if patients had no signs of delayed enhancement typical for ischaemic heart disease or delayed enhancement patterns of myocarditis. Magnetic resonance imaging represents a …