The use of Impella Recover in the treatment of post-infarction ventricular septal defect: a new case report.

Ventricular septal defect (VSD) can occur as part of more congenital cardiac malformations or as an isolated finding. VSD can be also a serious complication of acute myocardial infarction. It seems that its prognosis improves if the operation can be deferred for 3-4 weeks. The treatment of VSD is changing and the surgical closure should be postponed in order to reduce the mortality risk. The use of Impella Recover left ventricular assistance device allowed to delay the surgery, stabilizing the patient's hemodynamic condition. We describe a case of post-infarction VSD treated with the implantation of Impella Recover, which permitted to postpone a surgical closure for 2 weeks. Our results confirm the improvement of VSD's survival, depending on the use of Impella Recover, which allows to maintain the hemodynamic stability and to delay the operation.

Significant coronary artery disease associated with coronary artery aneurysm and elevation of prostate-specific antigen during acute myocardial infarction.

Coronary artery aneurysms are defined as coronary dilatations which exceed the diameter of normal adjacent segments by 1.5 times. Although more commonly associated with atherosclerosis, a variety of other acquired (eg, inflammatory, infectious, iatrogenic) or congenital causes have been identified that lead to impaired vessel media. A number of complications have been reported to occur during the course of the disease including thrombosis and distal embolization, myocardial ischemia and/or infarction, dissection, vasospasm, calcification, fistulization and rupture. Other complications relate to the size of the aneurysm and compression of adjacent structures. Prostate-specific antigen (PSA) is an established marker for detection of prostate cancer. Elevation of prostate-specific antigen as well as its diminution during acute myocardial infarction has also been reported. It seems that when elevation of prostate-specific antigen occurs during acute myocardial infarction, coronary lesions are frequent and often more severe than when diminution of prostate-specific antigen occurs. PSA has been identified as a member of the human kallikrein family of serine proteases. In recent years, numerous observations have suggested that the activity of the kallikrein-kinin system is related to inflammation and to cardiovascular diseases. We present a case of elevation of serum PSA concentration during acute myocardial infarction in a 64-year-old Italian man with significant coronary artery disease and coronary artery aneurysm. Also this case confirms previous findings and extends the evaluation of PSA during acute myocardial infarction. It confirms a possible new intriguing scenario of the role of the prostate-specific antigen in acute myocardial infarction.

Exercise-induced ST-segment depression in inferior leads during treadmill exercise testing and coronary artery disease.

The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest. The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. A review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. This experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance.

Sicilian DES Registry: prospective in-hospital and 9-month clinical and angiographic follow-up in selected high restenosis risk patients.

OBJECTIVE: This is a multicentre, open label, prospective non-randomized registry, with 9-month angiographic follow-up, conducted to evaluate the safety and effectiveness of drug-eluting stents (DES) when used in high restenosis risk patients from the real world. METHODS: From June 2004 to February 2005, a total of 1622 consecutive patients were enrolled to the Sicilian DES Registry, according to specific inclusion criteria. Both paclitaxel-eluting and sirolimus-eluting stents were used. The analysis was performed on 1472 patients because 150 patients were excluded from the study. The primary endpoint was to evaluate the rate of major adverse cardiac events (MACE) within 9 months after DES implantation. Major adverse cardiac events were defined as cardiac death, non-Q-wave or Q-wave myocardial infarction (MI) and target vessel revascularization (TVR). The secondary endpoints were procedural success, angiographic binary restenosis and stent thrombosis within 9 months post-procedure. RESULTS: Patients were more frequently male; 472 (32.1%) were diabetics, of whom 130 (27.5%) were treated with insulin. Mean ejection fraction of the left ventricle was 51.5 +/- 8.7%. Multivessel disease was found and treated in 627 patients (42.6%). A total of 2439 lesions were treated with DES. Final angiographic success was achieved in 2422 (99.3%) lesions. Procedural success was achieved in 1422 (96.6%) patients. The 9-month cumulative incidence of MACE was 7.3% with 0.8% of cardiac deaths, 0.8% non-fatal MI, 7.9% TVR. Binary restenosis was observed in 101 patients (8.3%). Stent thrombosis was documented in 11 patients (0.8%). CONCLUSIONS: Drug-eluting stents appear to be safe and associated with a low incidence of MACE at 9-month follow-up, even in patients selected for their complexity.

Correction of discrete subaortic stenosis with abnormal chordae tendineae.

The case of a 52-year-old woman with subvalvular aortic stenosis and aortic regurgitation is presented. Mitral regurgitation was associated, due to insertion of two abnormal chordae tendineae at the apex of the anterior papillary muscle and at the free border of the subvalvular membranous annulus. This abnormality displaced the anterior papillary muscle, thus applying a traction at the mitral leaflet. The patient was operated on through a valve-sparing approach, in which the discrete subaortic stenosis was removed through aortotomy and the ectopic chordae were excised. Suture mitral annuloplasty completed the procedure. Aortic and mitral insufficiency almost disappeared at follow-up. From the examination of this case and from a review of pertinent literature it emerges that in event of similar complex congenital abnormalities without intrinsic valve disease, a conservative approach should be chosen so that valve replacement can be avoided.

[Potential impact of drug-eluting stents in Sicily: results from a multicenter survey and cost-benefit analysis of drug-eluting stents versus bare metal stents]. / Impatto potenziale dello stent medicato nella pratica clinica siciliana: risultati di una "survey" multicentrica e di un'analisi costo-beneficio rispetto allo stent metallico.

BACKGROUND: The recent introduction of drug-eluting stents (DES) has shown, in randomized controlled trials, to reduce the incidence of restenosis as compared to bare metal stents (BMS). Since their cost is considerably higher than that of BMS, the study assessed the economic impact of the adoption of this new therapy in the Sicilian clinical practice. METHODS: An economic evaluation was carried out by means of a linear decision model developed in Excel that simulated and compared costs and clinical pathway, within 1 year of the intervention, of hypothetical groups of patients with de novo lesions undergoing angioplasty with DES or BMS. Clinical data were obtained from the available literature and adapted to the Sicilian reality, using data from an original survey conducted in 7 local cath labs. The survey collected information on the anatomical case-mix of the population treated, the average number of stents used in the various procedures and the methods of treatment for in-stent restenosis. RESULTS: Compared to BMS, DES allows to avoid, on average, 11.8 revascularizations out of 100 patients over a period of 1 year, but requires to bear an incremental net cost of Euro 931 for the annual treatment of each patient. The cost-benefit ratio is more favorable for those categories of patients/lesions in which the risk of in-stent restenosis is higher and, at the same time, the number of stents implanted per procedure is lower (single-vessel diabetics and small vessels). CONCLUSIONS: The results of the study show how, within the scope of a policy that has tended more and more to rationalize the use of available health resources, the use of the expensive DES is not justified from an economic point of view in groups of patients and types of lesions in which a BMS is also associated with a lower likelihood of revascularization. Therefore, the study provides a starting point for consideration by hospital centers, suggesting the use of a mixture of DES for the treatment of lesions/patients at the highest risk of restenosis and BMS for the treatment of lesions/patients at lower risk of re-intervention.

Diastolic paradoxic jet flow in patients with hypertrophic cardiomyopathy: report of two patients with different morphologic aspects.

BACKGROUND: In non-Asiatic population, apical hypertrophic cardiomyopathy represents 1% to 2% of hypertrophic cardiomyopathies. The presence of an apical ventricular aneurysm occurs in 1% of patients with the apical variant of hypertrophic cardiomyopathy. METHODS AND RESULTS: We present two patients with hypertrophic cardiomyopathy, both illustrating an early diastolic paradoxic jet flow between the apex and the middle area of ventricle. Such paradoxic flow is possibly due to the coexistence of mid-chamber obliteration and segmental wall motion abnormalities at the apex. The incidence and clinical significance of this flow pattern is still to be clarified.

[Salvage angioplasty in a patient with antiphospholipid antibody syndrome and cardiogenic shock]. / Angioplastica di salvataggio in paziente con sindrome da anticorpi antifosfolipidi e shock cardiogeno.

Antiphospholipid syndrome is a thrombotic disorder in which the clinical features are venous and/or arterial thrombosis, thrombocytopenia, and recurrent fetal loss. We describe the case of a 39-year-old woman affected by antiphospholipid syndrome and acute anterior myocardial infarction complicated by cardiogenic shock. The patient, after the failure of thrombolysis, was successfully treated by rescue angioplasty. The persistent thrombocytopenia of these patients may lead to safety problems in thrombolytic treatment; therefore, primary angioplasty may be considered the treatment of choice.

Concealed ventricular extrasystoles. A family of premature ventricular complexes with high spontaneous variability.

BACKGROUND: The term concealed ventricular extrasystoles defines a phenomenon in which premature beats have a cyclical distribution and manifest after a predictable number of intervening sinus beats. The extent of its spontaneous variability as well as the stability of its orderly distribution, however, have not been defined yet. The aim of this study was to assess whether there is any difference between the variability of concealed ventricular extrasystoles and their allorhythmic patterns. METHODS: The distribution of premature ventricular complexes (PVCs) was evaluated in 39 patients with frequent monomorphic PVCs (> 1000/die) during a baseline 24-hour ambulatory monitoring electrocardiogram. Patients were divided into two groups: group A had evidence of concealed ventricular extrasystoles, while in group B PVCs were randomly distributed. All patients underwent a second ambulatory monitoring electrocardiogram within 30-360 days. RESULTS: The overall number of PVCs did not differ between the groups. Patients of group A showed a very high spontaneous variability (p = 0.006) between the first and the second ambulatory monitoring electrocardiogram, whereas significant differences were not observed among patients of group B. CONCLUSIONS: Concealed ventricular extrasystoles are not casual and transient, but should be regarded as a marker of a "family" of PVCs that have the tendency either to maintain their orderly distribution for long periods or to disappear suddenly.