Effects of Acute Triiodothyronine Treatment in Patients with Anterior Myocardial Infarction Undergoing Primary Angioplasty: Evidence from a Pilot Randomized Clinical Trial (ThyRepair Study).

Background: Thyroid hormone has a differential action on healthy and ischemic heart. Triiodothyronine (T3) administration improved postischemic cardiac function while it limited apoptosis in experimentally induced ischemia. Thus, the present study investigated the potential effects of acute liothyronine (LT3) treatment in patients with anterior myocardial infarction. Methods: This study is a pilot, randomized, double-blind, placebo-controlled trial (ThyRepair study). We randomized 52 patients and analyzed data from 37 patients (n = 16 placebo and n = 21 LT3), per prespecified per protocol analysis. We excluded three patients who had died of cardiovascular causes (one in placebo and two in LT3 arm), four with small infarct size below a pre-specified threshold (in the placebo arm), and the rest, who lacked follow-up data. LT3 treatment started after stenting as an intravenous (i.v.) bolus injection of 0.8 µg/kg of LT3 followed by a constant infusion of 0.113 µg/kg/h i.v. for 48 hours. All patients had cardiac magnetic resonance (CMR) at hospital discharge and 6 months follow-up. The primary end point was CMR left ventricular (LV) ejection fraction (LVEF) and secondary endpoints were LV volumes, infarct volume (IV), and safety. Results: The CMR LVEF% at 6 months was 53.6 ± 9.5 for the LT3-treated group and 48.6 ± 11 for placebo, p = 0.15. Acute LT3 treatment resulted in a significantly lower LV end-diastolic volume index (92.2 ± 16.8 mL/m2 vs. 107.5 ± 22.2, p = 0.022) and LV systolic volume index (47.5 ± 13.9 mL/m2 vs. 61.3 ± 21.7, p = 0.024) at hospital discharge, but not at 6 months. There was no statistically significant difference in CMR IV at hospital discharge between the groups (p = 0.24). CMR IV tended to be lower in the LT3-treated group at 6 months (18.7 ± 9.5 vs. 25.9 ± 11.7, in placebo, p = 0.05). Serious, life-threatening events related to LT3 treatment were not observed. A tendency for an increased incidence of atrial fibrillation (AF) was found in the LT3 group during the first 48 hours (19% for T3 group vs. 5% for placebo, p = 0.13). Conclusion: This pilot randomized, placebo-controlled trial study suggests potential favorable effects (acute cardiac dilatation and 6-month IV) as well as potential concerns regarding a higher risk of AF after LT3 administration early after myocardial infarction, which should be tested in a larger scale study.

A giant, free-floating mass in the left atrium in a patient with atrial fibrillation.

A large intracardiac mass is a rare condition and one with an extremely high risk of haemodynamic and embolic complications. Urgent surgical excision is the treatment of choice, and the histological examination reveals the exact nature of the mass, usually a myxoma or a thrombus. We present the case of an 80-year-old woman, with a history of atrial fibrillation, who was admitted because of a seriously impaired level of consciousness, and fever. A large cerebral infarct and a urinary tract infarction were diagnosed. On the transthoracic echocardiogram a giant, free-floating mass was detected in the left atrium, transiently obstructing the mitral valve orifice. Based on the features of the mass and patient's history, it was considered more likely to be a thrombus rather than a tumour. Given the patient's extremely unfavourable neurological status, cardiac surgery was considered to be contraindicated and the patient was administered unfractionated heparin intravenously. Unfortunately, after a few hours the patient suffered a cardiac arrest and died.

Successful surgical repair of mitral valve prolapse endocarditis: a case report and review of the current literature.

We present the case of a 42-year-old man with mitral valve prolapse (MVP) and infective endocarditis. He was referred to our hospital by his family physician for the evaluation of a cardiac murmur. A detailed medical history revealed that he had been feeling fatigue with occasional episodes of slight fever during the last two months. Echocardiography revealed MVP with a sizeable vegetation and severe mitral insufficiency. Serial blood cultures were positive for Streptococcus viridans, highly penicillin susceptible. He was put on appropriate antimicrobial therapy, but both the vegetation and the concomitant mitral insufficiency persisted after otherwise successful medical therapy. Thus, the patient underwent surgical vegetectomy with mitral valve repair. He had an uneventful postoperative course and remains free of disease at the 12-month follow up. Our case report reinforces the value of early diagnosis in the presence of a high clinical suspicion of MVP endocarditis. An extended clinical workup, including serial detailed echocardiography studies, is mandatory in such a patient. Medical treatment of infective endocarditis in the setting of MVP is often successful. However, cardiac surgical intervention plays an important role in the treatment of intracardiac complications. Mitral valve repair in the context of a healed and stable infective endocarditis is the treatment of choice.

Incidental diagnosis of a large coronary fistula: angiographic and cardiac MRI findings.

Coronary artery fistulas are rare anomalies of the coronary arteries that may sometimes be totally asymptomatic and can be found incidentally during coronary arteriography later in adult life. We report the case of a 75-year-old man with such a fistula and describe our diagnostic approach. In addition, we review the literature on the etiology, epidemiology, the diagnostic modalities and treatment of coronary fistulas.

The role of the implantable loop recorder in the investigation of recurrent syncope.

Recurrent syncope is a common clinical problem. Patients with recurrent syncope frequently undergo extensive investigations that consume significant health care resources. Nevertheless, in a large percentage of patients syncope remains unexplained. The implantable loop recorder is a recognized diagnostic tool that can provide a definitive diagnosis and thus permit specific treatment. We present the case of a woman with recurrent syncope who was referred to our cardiology department for further investigation. Her last episode had led to a fall that caused her serious injuries. The initial routine workup was negative for cardiac, neurologic or metabolic causes of syncope. The implantable loop recorder revealed an arrhythmic origin for the recurrent syncope. The patient was managed appropriately with pacemaker implantation and has remained asymptomatic for one year.

Chest pain and ST-segment elevation in a patient with polymyositis: a case report.

BACKGROUND: Cardiac involvement in patients with polymyositis is well-documented and includes myocarditis, coronary arteritis, pericarditis, valvular dysfunction and arrhythmias. CASE REPORT: There are only few reports of acute myocarditis in patients with polymyositis and, although it usually follows a chronic, mild course, it may occasionally become life-threatening. We describe the case of a 36-year-old young woman suffering from polymyositis who presented with clinical signs and symptoms mimicking an ST Elevation Acute Coronary Syndrome. The atypical features of the pain, the young age of the woman, the lack of significant cardiovascular risk factors and the medical history of an autoimmune disease, led us to reconsider our initial diagnosis towards the presence of focal myocarditis. CONCLUSION: We describe our diagnostic approach and comment on our speculations and decisions about the treatment of such a life threatening event.

Acute anterior myocardial infarction after multiple bee stings. A case of Kounis syndrome.

A 58-year-old man with no history of cardiac diseases or cardiovascular risk factors was stung by honeybees. Soon after, he gradually developed signs of an allergic reaction followed by severe retrosternal pain. Electrocardiographic, echocardiographic evidence and positive biochemical markers were consistent with an acute anterolateral myocardial infarction. Coronary arteriography showed a left anterior descending artery thrombotic lesion. This is a case of Kounis syndrome, which is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity reactions as well as anaphylactic or anaphylactoid insults. The clinical implications and pathophysiology of this dangerous association are discussed.

Diabetic myocardial disease: pathophysiology, early diagnosis and therapeutic options.

Diabetes mellitus is a powerful risk factor for cardiovascular disease associated with high morbidity and mortality rates. Diabetic patients also have an increased incidence of heart failure which has been traditionally attributed to the concurrent presence of ischemic or hypertensive heart disease. Yet, nowadays, according to recent scientific evidence, diabetic myocardial disease (DMD) is more and more being considered as a distinct nosologic entity, independent of the co-existence of coronary artery disease, arterial hypertension or other risk factors, with the potential to lead to a self-existent progressive development of heart failure. In this article, we review the possible pathophysiologic mechanisms involved in the development of DMD as well as the structural and functional changes in the diabetic heart. We emphasize the importance of early detection of the syndrome, especially by novel echocardiographic techniques. Finally, we refer to the various therapeutic options for the optimal management of DMD according to the recent literature.

Multiple cardiac metastases from a malignant melanoma.

Metastatic tumors in the pericardium or the heart are more common than primary tumors and their incidence has increased during the last decades due to the prolonged survival of patients with cancer and the increased prevalence of the disease in the general population. We present the case of a 36-year-old patient admitted to our hospital due to fatigue, dyspnea, and episodes of dizziness and fainting during the last month. He had a history of a malignant skin melanoma surgically removed 4 years ago. The echo study identified multiple metastases in the heart involving the pericardium, the myocardium and the right atrium, where the tumor was mobile creating mechanical tricuspid valve stenosis. Malignant metastasis was confirmed by pericardiocentesis and, although treatment with chemotherapy was promptly initiated, the patient died 4 months later. Despite the difficulty in clinical diagnosis of cardiac melanoma, early detection has important therapeutic and prognostic implications. Echocardiography is the most common diagnostic modality and transesophageal approach may be the technique of choice to image intracardiac metastatic tumors.

Relation of coronary artery ectasia to diabetes mellitus.

An increased prevalence of coronary artery ectasia (CAE) and a low frequency of diabetes mellitus have been reported in patients with abdominal aortic aneurysm (AAA). The prevalence of diabetes was studied in 190 patients with CAE in comparison with 341 age- and gender-matched patients with coronary artery disease alone. Diabetes mellitus was found to be independently but inversely associated with CAE (relative risk 0.603, 95% confidence interval 0.375 to 0.960, p = 0.037), thus resembling the relation between diabetes and AAA.