ABSTRACT
Subvalvular left ventricular aneurysm is a rare disease of obscure origin suggesting unique causes such as congenital, traumatic, and inflammatory or infectious diseases. Its mortality is closely related to heart failure, mitral insufficiency, thromboembolic phenomena, and cardiac arrhythmias. Although association with coronary artery disease is not described, the compression of epicardial vessels by the aneurysm may lead to ischemic manifestations. We report here a case of mitral subvalvular left ventricular aneurysm of probable chagasic origin, in a patient with normal left ventricular function evolving with repeated episodes of monomorphic ventricular tachycardia, despite noninducible electrophysiological testing and the use of optimal medical treatment, including amiodarone. The indication for implantable cardioverter-defibrillator in patients with Chagas cardiomyopathy and segmental wall motion abnormalities but without global systolic dysfunction remains unclear in literature, even in the presence of complex ventricular arrhythmias. A brief review of the literature on morphological features, diagnosis, prognosis, and treatment will be also discussed.
ABSTRACT
Fractional flow reserve (FFR) has been proposed as the gold standard to assess functional severity of coronary artery stenosis and to stratify which lesions should be subjected to intervention (percutaneous coronary intervention [PCI]). A systematic review was performed in MEDLINE and EMBASE including studies indexed until November 2013 that used FFR for deferral or performance of PCI. Outcomes of interest were death, acute myocardial infarction (AMI), and new revascularization (RV). Nineteen studies were included, totaling 3,097 patients (3,796 lesions). Mean follow-up was 21.2 months. In indirect comparisons, FFR-PCI and FFR-defer groups had similar death (2.2% vs 2.0%, respectively, p = 0.86) and AMI rates (1.9% vs 1.9%, respectively, p = 1.00). RV rates were higher in the FFR-PCI group (14.0% vs 4.4%, p = 0.002). Direct comparisons (2-arm trials) also showed no differences in death (odds ratio [OR] 1.86 [95% CI 0.81 to 4.27], I(2) = 11.5, p = 0.14) and AMI rates (OR 0.75 [95% CI 0.21 to 2.69], I(2) = 47.1, p = 0.66); RV rates were again higher in the FFR-PCI (OR 3.10 [95% CI 1.25 to 7.70], I(2) = 72.2, p = 0.015). Meta-regression suggests influence of male gender on RV rates (ß = 0.058, p = 0.026). In conclusion, deferral of PCI based on FFR is a safe strategy. Considerable heterogeneity was observed, however.
