Favorable changes in arterial elasticity, left ventricular mass, and diastolic function after significant weight loss following laparoscopic sleeve gastrectomy in obese individuals.

BACKGROUND: Obesity is accompanied by increased arterial stiffness, left ventricular (LV) hypertrophy, and diastolic dysfunction, all associated with a negative prognosis. The evolution of LV mass, function, and arterial elasticity after laparoscopic sleeve gastrectomy (LSG) was unknown, and this is what we have investigated. METHODS: Thirty-four consecutive obese subjects (mean age, 39 ± 11 years; 35.2 % men), scheduled for LSG, were studied before, at 6 and 12 months after surgery. RESULTS: The body mass index (BMI) decreased from 43.6 ± 11.9 to 32.1 ± 7.4 and to 28.9 ± 5.8 kg/m(2) at 6 and 12 months after surgery (all p < 0.05). The baseline LV mass index was correlated with age, BMI, waist circumference, blood glucose level, systemic hypertension stage, and with aortic distensibility, strain, and stiffness index (all p < 0.05). Aortic distensibility increased by 110 %, aortic strain by 58 %, and aortic stiffness index decreased by 88 % at 6 months after LSG (all p(6 months-baseline) < 0.05) and all the parameters had similar values at 12 months postoperatively (all p(12-6 months) = NS). LV hypertrophy prevalence decreased from 61.8 to 47.1 % and to 32.3 % at 6 and 12 months after surgery (all p < 0.05). The proportion of patients with LV diastolic dysfunction decreased from 52.9 to 23.5 % at 6 months (p(6 months-baseline) < 0.01) and to 20.6 % at 12 months postoperatively (p(12 -6 months)= 0.7). CONCLUSIONS: Significant improvements of aortic elasticity and of LV diastolic function were recorded at 6 months, and they were maintained at 12 months after LSG. The LV hypertrophy showed also a favorable evolution: it has been slightly improved 6 months after surgery and further ameliorated 1 year postoperatively.

Portopulmonary hypertension: from diagnosis to treatment.

Portopulmonary hypertension is a form of pulmonary arterial hypertension that has gained interest in recent years with the development of liver transplantation techniques and new pulmonary vasodilator therapies. Portopulmonary hypertension is defined as pulmonary artery hypertension associated with portal hypertension with or without advanced hepatic disease. Echocardiography plays a major role in screening for portopulmonary hypertension but right heart catheterization remains the gold standard for diagnosis. The treatment of patients with portopulmonary hypertension consists of general measures that apply to all patients that carry the diagnosis of pulmonary hypertension and specific vasodilator therapies. These new therapies showed encouraging results in patients who would otherwise have a contraindication for liver transplantation. The review presents a summary of the current knowledge on the epidemiology, diagnosis, treatment and prognosis of patients with portopulmonary hypertension.

Right ventricular myocardial infarction and pulmonary embolism differential diagnosis--a challenge for the clinician.

It is frequently recognized in medical literature as well as in daily clinical practice that right ventricular myocardial infarction and pulmonary embolism are two of the most challenging clinical pictures to differentiate in cardiology and the treatment, often chosen upon a mixture of clinical suspicion criteria subsequently confirmed by other diagnostic methods, can lead to therapeutic success. Differential diagnosis is often difficult due to similar clinical picture, unspecific electrocardiographic changes and unspecific biological markers. It is very important to know the risk factors and the associated comorbidities for these two clinical entities in order to be able to interpret them contextually. In most cases the diagnosis key is the clinical suspicion. Usually in evaluating these cases we are in the position of choosing more complex diagnostic procedures, most likely not available in Emergency Department. In conclusion it is expected from the clinician to use the available methods with a thorough approach to details but in the same time considering the whole clinical picture.

Changes in plasma levels of MMP-9, MMP-7 and their inhibitors in patients with coronary artery disease.

UNLABELLED: To describe the enzymatic profile of plasma matrix metalloproteinases (MMP-7 and -9) and tissue inhibitors of metalloproteinases (TIMP-1 and -2) in different categories of patients (pts.) with coronary artery disease (CAD), and their relationship with clinical status, left ventricular (LV) function and remodelling. METHODS: Total plasma MMP7, active fraction of MMP9, TIMP1 and TIMP2 were determined in 68 consecutive pts with confirmed CAD (Group A, 56.6 +/- 9 y, 75% men, LVEF 56.4 +/- 11%) and compared with a control group of 23 pts. without cardiovascular disease and normal coronary arteries (Group B, 58.1 +/- 10 y, 56.5% men, LVEF 58.7 +/- 5%). LVEF and wall motion index (WMI) were computed. Diastolic function parameters were evaluated: mitral E/A ratio, E/E'septal ratio. We calculated global longitudinal (L), circumferential (C) and radial (R) strain (S) and strain rate (SR) values as the average of segmental values, by 2D strain analysis. RESULTS: The active form of MMP9 differed significantly between group A and B, as did the MMP9/TIMP1 and MMP9/TIMP2 ratios (8.78 +/- 10.0 ng/ml vs 3.33 +/- 4.0 ng/ml; 5.43 +/- 3.4 vs 0.85 +/- 0.9, and 11.60 +/- 5.2 vs 3.71 +/- 1.0, respectively, p < 0.04 for all). Group A included 35 pts. with acute coronary syndromes (ACS) and 33 pts. with stable angina (SA), with similar profile of LVEF and number of coronary arteries involved. There were no significant differences in plasma MMP9, MMP9/TIMP1 and MMP/TIMP2 ratio between normal and SA group, but only between normal and ACS group (p = 0.02 for MMP9). In group A, only MMP7, TIMP1/MMP7 and TIMP2/MMP7 ratio correlated with markers of systolic function: LVEF, WMI and global LS. CONCLUSION: There were no significant changes in extracellular matrix markers in pts. with chronic stable ischemia vs normals. Only active form of MMP9 and its ratio with TIMP differed significantly in ACS. Total MMP7 and its ratio with TIMP correlated with parameters of LV systolic function even in pts. with normal LVEF.

Circulating adiponectin: associations with risk factors and the Reynolds risk score in women without prior major cardiovascular events.

OBJECTIVE: Adiponectin may play an important role in the interplay between metabolic changes and cardiovascular risks. Our aim was to establish if plasma adiponectin can be used to detect the metabolic syndrome (MetS) in women without a history of major cardiovascular events and to evaluate its correlation with the global cardiovascular risk expressed by the Reynolds risk score (RRS). METHODS: 148 consecutive women without a history of cardiovascular events with or without MetS have been investigated. Clinical risks factors as well as plasma levels of lipids, fasting glucose and adiponectin were determined. RESULTS: As expected, circulating adiponectin was lower in women with MetS: 26.8 +/- 20.4 versus 44.3 +/- 26.7 microg/ml (p < 0.001) and inversely related to the number of MetS features (r = -0.33, p < 0.001). The latter was further associated with the total cardiovascular risk calculated using RRS (r = 0.49, p < 0.001). However, there was no relationship between circulating adiponectin and this score (r = -0.14, p = NS). CONCLUSIONS: Plasma adiponectin levels are significantly lower in women with MetS, but as a stand-alone tool plasma adiponectin may be of little value in the diagnosis MetS. Circulating adiponectin levels are not associated with the global cardiovascular risk calculated using RRS.

Echocardiography in congenital mitral valve regurgitation--the liaison between cardiologist and surgeon.

Congenital heart diseases are broadly defined as those cardiac anomalies that are present at birth. By their very nature, such defects have their origin in embryonic development. Congenital mitral valve regurgitation is a rare disease occurring in infancy or childhood. In up to 60% of cases, congenital anomalies of the mitral valve occur in association with other cardiac lesions, and often more than one component of the mitral apparatus is involved. The true incidence of congenital mitral valve regurgitation (MVR) is difficult to determine accurately (0.21-0.42% from total mitral valve regurgitations); isolated congenital mitral regurgitation is uncommon. The Carpentier classification of congenital mitral valve disease is the most commonly used nomenclature based on a functional analysis of the mitral valve leaflet. The contemporary anatomic classification has the advantage of minimizing observer variability in the diagnosis and it offers a much better liaison between the cardiologist and surgeon.

Shone's syndrome diagnosed with echocardiography and confirmed at pathology.

The Shone's complex, defined by four cardiovascular defects such as a supravalvular mitral membrane, valvular mitral stenosis by a parachute mitral valve, subaortic stenosis, and aortic coarctation, is a rare entity, which occurs most frequently in its incomplete form. We report the case of a 19-year-old female patient who presented at the emergency room for progressively worsening dyspnoea, orthopnoea, fever, and productive cough, due to bronchopneumonia. Echocardiography revealed the co-existence of aortic coarctation with bicuspid aortic valves, mitral supravalvular ring, and dysplastic mitral valves producing severe mitral stenosis and severe pulmonary hypertension. Although wide spectrum antibiotics were administered from the first day of hospitalization, the patient developed severe sepsis and died. The components of the Shone's complex diagnosed by echocardiography were confirmed at pathology.

Current challenges of anticoagulant treatment.

Anticoagulant therapy plays an important role in current medical practice. The main types of anticoagulant agents are: heparins, hirudins and vitamin K antagonists. None of the drugs used as anticoagulants meet the criteria of an ideal anticoagulant because they have side effects and they interact with other compounds. The main side effect of anticoagulant therapy is bleeding. The choice of a certain anticoagulant is made by the doctor based on the clinical context and also on the desired effect.

Cardiac tumors: the experience of a tertiary cardiology center.

UNLABELLED: Cardiac tumors represent a rare condition, often presenting with severe symptoms and having a poor outcome in the absence of early diagnosis and therapy. The aim of this study was to assess the prevalence and type of cardiac tumors, the techniques used for the diagnosis and the therapy used in a tertiary cardiology center. METHODS: During a 2-years period, among the 35004 patients (pts) hospitalized in our Cardiology Department, 24 pts were diagnosed with CTum (0.068% of all hospitalizations). A retrospective study of CTum cases was based on the patient files, with full clinical data, paraclinic investigations and therapy details. RESULTS: In the CTum group (49 +/- 16.2 years, similar between men and women), the main symptoms leading to patients referral were dyspnea (15 pts, 62.5%) and embolic events (coronary, cerebral, peripheral arteries: 7 pts, 29%), while in 4 asymptomatic pts the diagnosis was incidental. Transthoracic echocardiography (TTE) detected the presence of CTum in all cases. In 20 pts (83%), TTE and transesophageal echocardiography (TEE) provided all the data required for preoperative assessment (tumor size, extension, location, insertion site). In 4 pts, additional CT and MRI investigations were necessary, mainly for complex disease (malignant secondary CTum). The imaging techniques suggested a diagnosis of benign tumor in 15 pts (62.5%) and malignant tumor in 5 pts. In 4 pts the tumor type could not be established. Myxoma was the most frequent diagnosis (14 pts, 58% CTum). Among malignant CTum, secondary tumors (melanoma, lung and uterine cancer) were more frequent than primary CTum (4 vs 1 pt). The localization of CTum was intracavitary in 22 pts, 91% mainly in the left atrium (15 pts), intramyocardic in 1 pt and pericardic in 1 pt. Surgery was performed in 18 pts, confirming the preoperative diagnosis in 17 cases (94%). In one case, a myxochondrosarcoma was diagnosed at pathology in a patient with an echocardiography-based preoperative diagnosis of myxoma. CONCLUSIONS: CTum represent a rare condition, accounting for only 0.068% of hospitalizations in a tertiary cardiology center, but with severe clinical presentation. Echocardiography (TTE and TEE) is the essential imaging modality, allowing in most cases the diagnosis, classification and localization of CTum and their insertion site. CT and MRI are useful additional modalities in complex cases (mainly malignant primary and secondary CTum). In the case of benign tumors, surgery must be performed as soon as possible after the diagnosis has been established, whereas for malignant tumors there is still much controversy in what regards the benefits of surgery.

Spontaneous echo contrast of unexpected etiology.

Cor triatriatum sinister is a rare congenital anomaly characterized by the presence of a fibromuscular membrane dividing the left atrium into two chambers: one entering the four pulmonary veins, the other connecting to the mitral valve. The extent of the communication between the two chambers and the presence of associated lesions determine the severity of symptoms and the complications. We report the case of a 20-year-old man firstly diagnosed with obstructive cor triatriatum sinister and severe pulmonary hypertension.

Up to date in pharmacological treatment of dilated cardiomyopathy.

Dilated cardiomyopathy is a syndrome characterized by dilatation and impaired function of one or both ventricles and represents the most common heart failure entity requiring heart transplantation. The treatment we currently use does not directly influence specific underlying pathomechanisms of this disorder, and several attempts are being made in order to introduce more specific therapies. We summarized the most important pharmacological strategies that are being evaluated for the treatment of dilated cardiomyopathy and pointed out the novel therapeutic approaches concerning heart failure secondary to this clinical condition.