S. Nodari

Effects of n-3 Polyunsaturated Fatty Acids on Left Ventricular Function and Functional Capacity in Patients With Dilated Cardiomyopathy

Methods Patients with chronic HF due to NICM and minimal symptoms while receiving evidence-based therapy were enrolled. LV function and functional capacity were assessed prospectively by echocardiography, cardiopulmonary exercise test, and New York Heart Association functional class at baseline and at 12 months after randomization to eithe r2go f n-3PUFAs or placebo. Results At 12 months after randomization, the n-3 PUFAs group and the placebo group differed significantly (p 0.001) in regard to: 1) LV ejection fraction (increased by 10.4% and decreased by 5.0%, respectively); 2) peak VO2 (increased by 6.2% and decreased by 4.5%, respectively); 3) exercise duration (increased by 7.5% and decreased by 4.8%, respectively); and 4) mean New York Heart Association functional class (decreased from 1.88 0.33 to 1.61 0.49 and increased from 1.83 0.38 to 2.14 0.65, respectively). The hospitalization rates for HF were 6% in the n-3 PUFAs and 30% in the placebo group (p 0.0002). Conclusions In patients with NICM and minimal symptoms in response to evidence-based medical therapy, n-3 PUFAs treatment increases LV systolic function and functional capacity and may reduce hospitalizations for HF. Given these promising results, larger studies are in order to confirm our findings. (J Am Coll Cardiol 2011;57:870‐9)

Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome

Aims/objectives:  This review examines the ‘tako‐tsubo‐like’ syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome.

Lack of tolerance development during chronic ibopamine administration to patients with congestive heart failure.

SummaryBeta-adrenergic agonists can progressively lose their efficacy during chronic therapy in patients with heart failure. Ibopamine is a new dopamine derivative, active on dopaminergic and beta-adrenergic receptors, whose hemodynamic activity has been acutely demonstrated. To assess whether any attenuation of its efficacy occurs, the variations of the cardiac output induced during chronic therapy were monitored by impedance cardiography in 15 patients with dilated cardiomyopathy who showed a significant increase of the cardiac output (20.7 ± 10.0%) after acute ibopamine administration. The efficacy of ibopamine was also assessed after 6 and 12 months of therapy by echocardiography, exercise testing, and 24-hour dynamic electrocardiogram (EKG) monitoring.The cardiac output response to ibopamine did not show any significant attenuation (range 15% to 19%) in the evaluations at 1, 2, 3, 4, 8, and 12 months of therapy. No significant change, was noted, after 6 and 12 months, in the exercise capacity (505 vs. 602 and 604 seconds) and the fractional shortening (16.2 vs. 18.3 and 18.5) without any change of the diastolic diameter. Ventricular arrhythmias were significantly reduced after 6, but not 12, months of therapy. No significant change in the New York Heart Association (NYHA) functional class was noted at 6 and 12 months of therapy (2.4 ± 5 vs. 2.3 ± 7 and 2.4 ± 0.6, respectively). Our results show that ibopamine can maintain its hemodynamic activity even during chronic therapy.

Efficacy of Ibopamine Treatment in Patients with Advanced Heart Failure: Purpose of a New Therapeutic Scheme with Multiple Daily Administrations

Eighteen patients with severe unstable heart failure who presented with hemodynamic deterioration after withdrawal of i.v. dopamine were treated with high doses of ibopamine (100 mg eight times a day, orally) in association with digitalis, diuretic, and vasodilator therapy. Ibopamine, used at these dosages, could effectively substitute for the i.v. infusion of dopamine in 15 of the 18 studied patients. Each patient was studied by right heart Swan-Ganz catheterization and two-dimensional echocardiography before and during ibopamine infusion, after dopamine withdrawal, and after acute ibopamine administration; measurements were then made after 3 months of chronic ibopamine treatment (100 mg eight times a day). Blood samples for plasma dopamine and epinine concentrations were obtained at the time of the hemodynamic measurements. Both drugs did not induce any significant change in arterial pressure whereas heart rate was slightly reduced after dopamine and chronic ibopamine. Cardiac index and stroke volume index were significantly increased by dopamine (from 1.81 to 2.24 L/ min/nr and from 20.3 ± 6.5 to 27.7 ± 8.1 ml/beat/m2) and acute and chronic ibopamine (from 1.80 to 2.15 and 2.23 L/min/nr and from 22.4 ± 6.8 to 28.2 ± 7.5 and 30.3 ± 7.0 ml/beat/nr. respectively); these changes were attended by a decrease in systemic vascular resistance: pulmonary pressures were not significantly modified. No significant change of the echocardiographic parameters was noted. During dopamine infusion, mean dopamine plasma concentrations were 211.8 ± 32.4 pmol/ml; after acute and repeated administration of ibopamine, free epinine plasma concentrations averaged 45.1 ± 14.5 and 62.2 ± 12.7 pmol/ml, respectively. Among the hematochemical parameters, plasma sodium concentration tended to decrease during chronic ibopamine and plasma creatinine was reduced by both dopamine and ibopamine. The New York Heart Association functional class significantly improved, averaging 3.9 before and 3.1 after chronic ibopamine. The survival rate, excluding four patients who underwent heart transplantation, was 71% at 6 months and 61% at 12 months. In conclusion, we think that frequent daily administrations of ibopamine can adequately substitute for i.v. dopamine; this therapeutic scheme can be used in patients awaiting cardiac transplantation.

Thrombus or tumor? a case of fibroelastoma as indicated during the submission process

We describe the case of a 50-year-old woman who was admitted to a pheriferal department for heart failure. The echocardiography revealed a small mass measuring about 1.3 × 1.0 cm adhering to the non-coronary cusp of the aortic valve, mild dilated cardiomiopathy and severe biventricular dysfunction. This mass had erroneously been considered a thrombotic lesion, so the patient was treated with thrombolysis and heparin e.v. Only after a transoesophageal echocardiography a tumour cardiac mass was suspected. The diagnosis of fibroelastoma was confirmed by MRI and then from the anatomic and histoligical definition after surgery.

Valutazione economica della resincronizzazione cardiaca nei pazienti affetti da scompenso cardiaco moderato-avanzato

SummaryObjectivePatients with severe heart failure, refractory to drug treatment, can be indicated for biventricular pacing, shown to be useful in overcoming the desynchronization of the ventricular contraction pattern, which generally worsens the hemodynamic conditions of such patients.This study was aimed at assessing 1) clinical effectiveness of conventional therapy compared with biventricular pacemaker; 2) hospital ward’s budget before and after device implantation.MethodsThe study was carried out according to an observational method, on 30 patients, retrospectively 1-year before implantation and prospectively 1-year afterwards. The economic analysis was designed and carried out in the hospital perspective. End-points were: Ejection fraction, New York Heart Association (NYHA) class, no. of hospitalizations in Cardiology Ward and ICU (Intensive Care Unit), Days of hospitalization in Cardiology Ward and ICU, no. of clinic visits (outpatients), no. of day-hospital visits, no. of days free from acute events requiring hospitalization or clinic visits, health care costs.ResultsIn the 12 months following biventricular pacing, patients showed: a reduction in functional NYHA class (3.0 ± 0.3 vs 2.1 ± 0.3); a reduction in cardiovascular related hospital stays (from 42.0 ± 37.5 days to 2.8 ± 6.4); an increase in number of days free from acute events (from 104 ± 123 to 266 ± 137). Overall costs decreased from € 383,518 to € 289,890 (with implant costs) and to € 58,549 (without implant costs). In-hospital stays in Cardiology and Coronary Unit decreased by 93% and 95%, respectively.ConclusionsBiventricular pacing in heart failure patients represents an efficient approach in the hospital perspective and allows a less intensive use of clinical resources. Even if other non-hospital-sustained costs are not taken into consideration, it seems reasonable to deduce that the significant improvement in patient’s clinical condition after implantation will provide a considerable reduction of total costs also in a broader perspective.

Physiopathology of Sudden Cardiac Death

Sudden cardiac death (SCD) is unexpected natural death due to cardiac causes, with abrupt loss of consciousness within 1 h of the onset of acute symptoms, with or without pre-existing heart disease. It is very hard to assess the exact incidence of SCD because of variability in the definition of the concept of “sudden” [1,2]. We are not discussing death occurring 1 h after syncope in a healthy subject, but the definition is not completely clear in a cardiopathic patient with ventricular fibrillation as the end-stage event in a worsened clinical status.

Biventricular Cardiac Resynchronization in Moderate-to-Severe Heart Failure: Analysis of Hospital Costs and Clinical Effectiveness (Brescia Study)

Heart failure is a chronic condition of complex physiopathologic origin which involves escalating clinical costs [1-3]. Cardiac resynchronization therapy is a novel treatment for the one in every six heart failure patients whose condition is refractory to optimized drug treatment, with evidence of ventricular dysynchrony which leads to a deterioration of hemodynamics and a higher risk of death [4-7]. In such hearts the regions which activate in advance will experience or receive a lower afterload, and the rapid presystolic contraction does not convert into a rise in pressure, because the other parts of the myocardium are still inactive. As a consequence, most myocardial activity is wasted in transferring the ejection from one part of the heart to another. This results in a lengthening of the ventricular pre-ejection period, a reduction of the contraction and the relaxation period, a reduction of the ejection fraction, and a rise in mitral regurgitation.

Acute and Chronic Effects of Nisoldipine in Patients with Chronic Heart Failure

In patients with heart failure, excessive rise in systemic vascular resistance leads to further impairment of left ventricular (LV) systolic function. Thus arterial vasodilators have been introduced as agents to improve hemodynamics. Calcium antagonists are among the most powerful arterial vasodilating drugs and have been proposed as myocardial unloading agents in the treatment of patients with depressed LV function [7,9,10,15]. However, their use has yielded controversial results, and in some studies a significant percentage of patients showed hemodynamic deterioration after acute or chronic administration [1,3,4,13], due to the negative inotropic activity and neurohumoral activation consequent to the excessive fall in peripheral resistances. To overcome these limitations new calcium antagonists with a more selective action on smooth muscle have been synthesized. Nisoldipine is a new dihydropyridine derivative characterized by a more potent action on peripheral vascular smooth muscle and by a longer half-life than the parent compound nifedipine [5]. This drug therefore seems particularly useful for the treatment of patients with heart failure as it presents a more selective action on peripheral resistances with less direct negative inotropic effects. Nisoldipine has been shown to exert favorable acute hemodynamic effects [11,17–19]; however, its effect during chronic treatment and on exercise capacity are still partially unsettled.