Cardiac papillary fibroelastoma: source of cerebral embolism treated with intravenous thrombolysis.

We present the case of a 41-year-old man with sudden development of left hemiparesis due to infarction of the right middle cerebral artery that was successfully treated with intravenous (IV) thrombolysis with alteplase. Transthoracic echocardiography showed a small mass in the left ventricle. The patient underwent surgical resection, and histological examination of the mass confirmed the diagnosis of papillary fibroelastoma. It remains to be investigated whether heart ultrasound evaluation should be performed before IV thrombolysis in selected patients with stroke, given the apparently increased risk of bleeding. However, IV thrombolysis should not be postponed due to a lengthy investigation, because of its potential for reducing morbidity in patients with stroke.

The shape of the aortic outflow velocity profile revisited: is there a relation between its asymmetry and ventricular function in coronary artery disease?

AIMS: Myocardium contracts in the beginning of ejection causing outflow acceleration, resulting in asymmetric outflow velocity profiles peaking around one-third of ejection and declining when force development declines. This article aimed to demonstrate that decreased contractility in coronary artery disease (CAD) changes outflow timing and profile symmetry. METHODS AND RESULTS: Seventy-nine patients undergoing routine full dose dobutamine stress-echo (DSE) were divided into two groups based on resting wall motion and DSE response: DSE negative (DSE(neg)) (35 of 79 patients) and positive (DSE(pos)) (44 of 79 patients) which were compared with 32 healthy volunteers. Aortic CW-Doppler traces at rest were analysed semi-automatically; time-to-peak (T(mod)), ejection-time (ET(mod)), rise-time (t(rise)), and fall-time (t(fall)) were quantified. Asymmetry (asymm) was calculated as the normalized difference of left and right half of the spectrum. Normal curves were triangular, early-peaking, whereas patients showed more rounded shapes and later peaks. T(rise) was longest in DSE(pos). T(fall) was shortest in DSE(pos), followed by controls and DSE(neg). Asymm was lowest in DSE(pos), followed by controls and DSE(neg). Abnormally symmetric profiles (asymm <0.25) were found in none of the controls, 2.9% DSE(neg), and 27.3% DSE(pos). A good correlation was found between assym and ejection fraction (EF) and T(mod)/ET(mod) and EF. Notably, an LV dynamic gradient was induced in 71.4% DSE(neg) and in 18.2% DSE(pos), associated with LV hypertrophy and supernormal (very asymmetric) traces. CONCLUSION: Decreased myocardial function results in a more symmetrical outflow, while very asymmetrical traces suggest increased contractility, potentially inducing intra-cavity gradients during DSE. Therefore, including outflow symmetry as a clinical measurement provides additional information on patients with CAD.

Early detection of left ventricular diastolic dysfunction in hypertensive heart disease by color Doppler myocardial imaging.

AIM: To determine if Color Doppler myocardial imaging could provide evidence of diastolic dysfunction in patients with hypertension whose pulse-wave Doppler parameters were normal. METHOD: The study included 33 patients (mean age 48+/-7.3 years) and a control group of 13 sex- and age-matched healthy individuals. Patients were divided into two groups according to mean blood pressure (BP) values during 24-hour blood pressure monitoring while under antihypertensive therapy: those with uncontrolled hypertension (n=22) and those with controlled hypertension (n=11). All study participants underwent complete standard echocardiography (2D, M-mode, pulsed and continuous Doppler) and a Color Doppler myocardial imaging study. RESULTS: Conventional Doppler parameters indicated relaxation disturbances in patients with uncontrolled hypertension, but were within a normal range in patients with controlled hypertension at baseline and follow-up. Parameters of global diastolic function measured by Color Doppler myocardial imaging revealed that E'/A', the ratio between E'-wave (early filling phase) and A'-wave (late diastolic wave due to atrial contraction), was <1 in 57% of segments at baseline in patients with uncontrolled hypertension, and did not significantly change at follow-up. In patients with controlled hypertension, E'/A'<1 was noted in 4.7% of segments at baseline and in 28.6% of segments at follow-up. CONCLUSION: Regional diastolic dysfunction measured by Color Doppler myocardial imaging was the first sign of myocardial dysfunction due to arterial hypertension, while the parameters of global diastolic dysfunction measured by conventional Doppler and Color Doppler myocardial imaging were still normal. Furthermore, in patients with uncontrolled hypertension with manifested global diastolic dysfunction, there was a change in late diastolic parameters. Our results point to a potentially important role of Color Doppler myocardial imaging in diagnosing hypertensive heart disease as well as in follow-up of treatment.

Efficacy and tolerability of delapril plus indapamide versus lisinopril plus hydrochlorothiazide combination treatments in mild to moderate hypertension: a multicenter, randomized clinical study.

BACKGROUND: Several studies have shown that antihypertensive monotherapy is commonly insufficient to control blood pressure (BP) in hypertensive patients and that concomitant use of ≥2 drugs is necessary in ∼50% of these patients. The combination of an angiotensin-converting enzyme (ACE) inhibitor and a diuretic, delapril plus indapamide (D + I), has been shown to be effective and tolerable, with no interaction between the 2 components. Another widely used combination of ACE inhibitor and diuretic is lisinopril plus hydrochlorothiazide (L + H). OBJECTIVES: The aims of this study were to confirm the antihypertensive efficacy and tolerability of the fixed combination of D + I in mild to moderate hypertension, and to compare its therapeutic efficacy and tolerability with that of L + H. METHODS: The antihypertensive efficacy and tolerability of a fixed combination of D + I (30-mg + 2.5-mg tablets once daily) or L + H (20-mg + 12.5-mg tablets once daily) in patients with mild to moderate hypertension were compared in a multinational, multicenter, randomized, 2-armed, parallel-group study. Eligible patients were aged 18 to 75 years and had a diastolic blood pressure (DBP) 95 to 115 mm Hg and a systolic blood pressure (SBP) ≤180 mm Hg, both measured in the sitting position. After a single-blind, placebo run-in period of 2 weeks, patients were randomized to receive 1 of the 2 treatments for a 12-week period. The primary efficacy end point was the BP normalization rate (ie, the percentage of patients with a sitting DBP ≤90 mm Hg) after 12 weeks of treatment. Secondary end points were as follows: (1) the responder rate (ie, the percentage of patients whose sitting DBP was reduced by ≥10 mm Hg from baseline or had a DBP ≤90 mm Hg after 12 weeks of treatment), (2) the percentage of patients with a DBP ≤85 mm Hg, and (3) changes in sitting SBP and DBP after 4, 8, and 12 weeks of treatment. RESULTS: A total of 159 hypertensive patients (88 women, 71 men) were randomized to receive D + I (44 women, 36 men; mean [SD] age, 53 [(11)] years) or L + H (44 women, 35 men; mean [SD] age, 55 [(10)] years). No significant between-group differences were found in any of the primary or secondary end points of the study. Both combinations induced a significant reduction in sitting DBP and SBP from baseline (P<0.001 for both groups at week 12), without significant differences between the groups. Five mild to moderate adverse drug reactions (ADRs) occurred in each treatment group. No patient dropped out of the study because of an ADR. CONCLUSION: This study showed no difference between D + I and L + H interms of antihypertensive efficacy or tolerability in patients with mild to moderate hypertension.

[Endocarditis associated with atrial and ventricular cardiac pacing leads. Case report]. / Endokarditis na atrijskoj i ventrikulskoj elektrodi trajnog elektrostimulatora srca. Prikaz bolesnika.

The infection of a transvenous lead implanted for cardiac stimulation is a rare, but serious complication. We report observation of a 25-year old man whose Staphylococcus epidermidis sepsis linked to endocarditis was related to atrial and ventricular pacing leads, and was diagnosed after two months of medical treatment. The most important role during the diagnostic process was played by the echocardiographic examination, especially transoesophageal, which revealed the large vegetations on atrial as well as ventricular pacing lead. The diagnosed condition was treated by complete removal of pacing system using open chest surgery and cardiopulmonary pump. After four weeks of vigorous antibiotic treatment, a new DDDR pacing system was implanted, but with epicardial leads.