A case report of right coronary artery agenesis diagnosed by computed tomography coronary angiography.

INTRODUCTION: Single coronary artery is a rare condition characterized by the origin of a coronary that supplies the entire heart from a single coronary ostium. PATIENT CONCERNS: A 45-year-old woman with an altered exercise testing was addressed to a computed tomography coronary angiography (CTCA) to rule out coronary artery disease (CAD). DIAGNOSIS: CTCA examination showed the absence of the right coronary artery (RCA). The left anterior descending artery and the left circumflex artery (LCX) presented regular origin and course and LCX provided the posterior interventricular artery and the posterolateral artery. INTERVENTIONS: As CTCA highlighted the absence of potentially life-threatening features related to coronary anomaly, no surgical treatment was advised. OUTCOMES: The patient was dismissed, kept under pharmacological control and monitored over time. CONCLUSION: CTCA is the first-choice imaging modality in patients with ECG abnormalities properly allowing the differential diagnosis between CAD and congenital heart disease.

SAT-TAVI (single antiplatelet therapy for TAVI) study: a pilot randomized study comparing double to single antiplatelet therapy for transcatheter aortic valve implantation.

BACKGROUND: Common clinical practice recommends dual antiplatelet therapy (DAPT) for transcatheter aortic valve implantation (TAVI). The aim of the study was to evaluate, in a double blind randomized study, the safety of TAVI, with adjunctive pharmacotherapy consisting of single antiplatelet therapy. METHODS AND RESULTS: From April 2010 to April 2011, 120 consecutive patients, undergoing TAVI, have been enrolled in the study. Patients were randomly assigned to DAPT group (aspirin and clopidogrel 75 mg/qd or ticlopidine 500 mg/bid) or ASA group (aspirin only). TAVI device was the Sapien XT-Novaflex Delivery System (Edwards Lifesciences, Inc.). All patients were followed up to 6 months. Device success was achieved in 100% of patients. No difference in the VARC combined 30 day safety endpoint, all cause and cardiovascular mortality was observed. At 30 days vascular complications were reduced in the ASA group (p<0.05). No differences in the clinical status were detected between the groups up to 6 months. CONCLUSIONS: This study suggests that TAVI procedures can be performed without DAPT without increasing the morbidity and mortality. These findings, if confirmed in a larger multicenter randomized trial, will no longer support the use of DAPT for TAVI.

Effect of concomitant oral chronic dipyridamole therapy on inflammatory cytokines in heart failure patients.

BACKGROUND: To assess whether dipyridamole therapy exerts a significant anti-inflammatory effect in heart failure patients. METHODS: We performed a retrospective analysis of the stored bio-samples of 3 groups of patients: 1) 25 normal healthy controls (N); 2) 25 heart failure patients (HF) under standard optimal therapy, including aspirin; 3) 17 HF patients with previous stroke and under clinically-driven therapy with A (Aggrenox, long-acting dipyridamole 200 mg + aspirin 25 mg, twice daily) for at least 1 month (HF-A). In all, we evaluated interleukin (IL)-6, adiponectin and C-reactive protein (CRP) as well as NT-proBNP. The same laboratory measurements were performed in the 17 HF patients with recent or previous stroke, both before and 1-month after clinically driven administration of A. RESULTS: All laboratory inflammatory indices were significantly higher in HF patients compared to N: IL-6 (N = 0.68 (0.3 - 12.7) vs. HF = 3.10 (0.5 - 16.7) vs. HF-A = 1.24 (0.3 - 3.3) pg/mL; p < 0.001 N vs. HF, p < 0.01 N vs. HF-A, p = ns HF vs. HF-A); CRP (N = 0.12 (0.01 - 0.45) vs. HF = 0.58 (0.04 - 2.7) vs. HF-A = 0.72 (0.02 - 4.8) mg/dL; p = ns N vs. HF, p = 0.05 N vs. HF-A, p = ns HF vs. HF-A); Adiponectin (N = 8.8 (3.0 - 31.4) vs. HF = 12.16 (4.9 - 27.3) vs. HF-A = 10.0 (4.8 - 15.6) pg/mL; p < 0.05 N vs. HF, p = ns N vs. HF-A p = ns HF vs. HF-A). NT-proBNP was also increased (N = 42.2 (13 - 93) vs. HF = 1907 (18.1 - 8038) vs. HF-A = 497.9 (7.8 - 3686) pg/mL; p < 0.001 N vs. HF, p = 0.01 N vs. HF-A, p = ns HF vs. HF-A). In 17 subjects, the intra-patient assessment (before and 1-month after starting of Aggrenox therapy) did not show a decrease in inflammation markers. CONCLUSIONS: HF patients show an increase in inflammatory indices independently of underlying A therapy.

Carcinoid Heart Disease: A Rare Cause of Right Ventricular Dysfunction Evaluation by Transthoracic 2D, Doppler and 3-D Echocardiography.

Carcinoid heart disease is a rare cause of heart failure with or without right valvular heart impairments. In this study, we showed a case of carcinoid tumour with hepatic metastases inducing carcinoid heart disease. Neuroendocrine heart involvement happens for severe tricuspid valve insufficiency and plaques on right ventricular (RV) walls produced by a release of serotonin (5-HT). A patient affected by primitive ileal tumour with 5-HT-secernent hepatic metastases inducing tricuspid insufficiency is showed. Transthoracic 2-D echocardiography showed tricuspid valve regurgitation and both right atrium, RV-walls plaques and RV dilation. Continue-wave Doppler showed a characteristic "dagger shaped" spectrum of tricuspid systolic flow. RV function was evaluated with 3-D transthoracic echocardiography. In particular, RV volumes, RV ejection fraction and stroke volume were defined by this technique. 2, 3-D echocardiography and Doppler method are useful techniques to show heart valves' derangements and RV function to non-invasively detect RV impairments in carcinoid heart disease.

Acute left main obstructions following TAVI.

AIMS: Transcatheter aortic valve implantation (TAVI) is becoming a safe and effective technique for treating symptomatic aortic valvular stenosis (AVS) as an alternative to surgery in very high-risk patients. A possible consequence of valve implantation is the obstruction of coronary ostia. METHODS AND RESULTS: Here we report five cases of angiographically confirmed left main (LM) obstruction, occurred immediately after balloon expandable aortic valve implantations at our institution. In four of these cases, LM obstruction was resolved with an emergency percutaneous coronary intervention (PCI). In the remaining case, obstruction transiently occurred only at the time of balloon valvuloplasty and did not required treatment. During this type of intervention, performing an aortography at the time of balloon valvuloplasty could help to identify patients at risk for coronary obstructions. CONCLUSIONS: These cases illustrate that obstruction of the coronary ostia following TAVI is a possible complication. As the use of TAVI becomes widespread, the operators should be aware of this dangerous complication in their case preparation should it arise.

Management of percutaneous aortic valve malposition with a transapical "valve-in-valve" technique.

Transcatheter aortic valve replacement is an emerging therapeutic alternative for patients with severe aortic valve stenosis and high surgical risk. The inability to reposition the current prosthesis is a limiting feature of these devices. Here we report on a case of a 74-year-old woman, in which a balloon expandable aortic valve malpositioning was treated with a second transapical transcatheter aortic valve implant.

Stress induced cardiomyopathy presenting as acute coronary syndrome: Tako-Tsubo in Mercogliano, Southern Italy.

BACKGROUND: Tako-tsubo syndrome (TTS) in its typical (apical) and atypical (non-apical) forms is being increasingly recognized in the West owing to early systematic coronary angiography in acute coronary syndromes (ACS). AIM OF THE STUDY: To assess the incidence, the clinical characteristics and the outcome of TTS in a single high volume cath lab in Southern Italy over the last 6 years. METHODS: Among 1674 consecutive patients (pts) referred to our coronary care units in the last 6 years (2001-2006) for ACS we selected 6 (0.5%) pts (6 women; age 57 +/- 6 years) who fulfilled the following 4 criteria: 1) transient left ventricular wall motion abnormalities resulting in ballooning at contrast ventricolographic or echocardiographic evaluation; 2) normal coronary artery on coronary angiography performed 5 +/- 9 hours from hospitalization; 3) new electrocardiographic ischemic-like abnormalities (either ST-segment elevation or T-wave inversion) and 4) emotional or physical trigger event. RESULTS: At admission all pts had presumptive diagnosis of ACS and ECG revealed ST elevation in 3 (50%) and T wave inversion with QT elongation in 3 (50%). In the acute phase cardiogenic shock occurred in 2 (33%) and heart failure in 1(16%). Presenting symptoms were chest pain in 6 (100%), dyspnoea in 2 (33%) and lipotimia in 1 (16%). At echocardiographic-ventricolographic assessment, the mechanical dysfunction (ballooning) was apical in all 6 pts ("classic" TTS). In all patients wall motion abnormalities completely reversed within 4.5 +/- 1.5 days. The region of initial recovery was the anterior and lateral wall in 4 cases and the lateral wall in 2 cases. Ejection fraction was 35 +/- 8% in the acute phase and increased progressively at discharge (55 +/- 6%) and at 41 +/- 20 months follow-up (60 +/- 4%, p < 0.001 vs. baseline). All patients remained asymptomatic with minimal (aspirin, beta blockers, antihypertensive and antidislipidemic therapy) treatment. CONCLUSION: Classic TTS is a frequent serendipitous diagnosis after coronary angiography showed "surprisingly" normal findings in a clinical setting mimicking an ACS. Despite its long-term good prognosis life threatening complications in the acute phase can occur.

Long-term performance of coronary sinus leads used for cardiac resynchronization therapy.

BACKGROUND: Little is known regarding the long-term performance of coronary sinus (CS) leads, which have an effect on the longevity of cardiac resynchronization therapy (CRT) systems. METHODS: This study included 109 patients (79 men) whose mean age was 68 +/- 9 years, New York Heart Association (NYHA) functional class 3.2 +/- 0.5, and left ventricular ejection fraction 25.6 +/- 6.6%, and who underwent CRT (n = 45) or CRT-D (n = 64) systems implants for management of idiopathic (53%), ischemic (40%), or miscellaneous (7%) dilated cardiomyopathy. Unipolar (n = 57) or bipolar (n = 52) leads were placed into the CS venous system. RESULTS: At implant, no significant difference was observed between unipolar and bipolar leads with respect to mean sensing performance (14 +/- 6 mV vs 14 +/- 8 mV, P = 0.97), pacing impedance (875 +/- 234 ohms vs 943 +/- 331 ohms, P = 0.24), and stimulation energy threshold (2 +/- 3.2 muJ vs 1.13 +/- 1.5 muJ, P = 0.08). At a median follow-up of 33 months, a significant decrease in stimulation impedance and increase in stimulation energy threshold was observed with unipolar (689 +/- 122 vs 875 +/- 234 ohms, P < 0.01, and 8.34 +/- 10.4 muJ vs 2 +/- 3.2 muJ, P < 0.001, respectively) as well as with bipolar (735 +/- 268 ohms vs 943 +/- 331 ohms, P < 0.01, and 4.81 +/- 9.92 vs 1.13 +/- 1.5 muJ, P = 0.02, respectively) leads. No significant difference in sensing performance was observed with either type of lead (10 +/- 5 mV vs 14 +/- 6 mV and 10 +/- 6 mV vs 14 +/- 8 mV, respectively). At long-term follow-up, no significant difference among any sensing or stimulation parameter was observed between unipolar and bipolar leads. CONCLUSIONS: At long-term follow-up, a significant increase in the energy required for stimulation was observed, whereas sensing performance remained unchanged. The increase in energy capture threshold was less marked with bipolar than with unipolar leads.

Pacing stress echocardiography.

BACKGROUND: High-rate pacing is a valid stress test to be used in conjunction with echocardiography; it is independent of physical exercise and does not require drug administration. There are two main applications of pacing stress in the echo lab: the noninvasive detection of coronary artery disease through induction of a regional transient dysfunction; and the assessment of contractile reserve through peak systolic pressure/ end-systolic volume relationship at increasing heart rates to assess global left ventricular contractility. METHODS: The pathophysiologic rationale of pacing stress for noninvasive detection of coronary artery disease is obvious, with the stress determined by a controlled increase in heart rate, which is a major determinant of myocardial oxygen demand, and thereby tachycardia may exceed a fixed coronary flow reserve in the presence of hemodynamically significant coronary artery disease. The use of pacing stress echo to assess left ventricular contractile reserve is less established, but promising. Positive inotropic interventions are mirrored by smaller end-systolic volumes and higher end-systolic pressures. An increased heart rate progressively increases the force of ventricular contraction (Bowditch treppe or staircase phenomenon). To build the force-frequency relationship, the force is determined at different heart rate steps as the ratio of the systolic pressure (cuff sphygmomanometer)/end-systolic volume index (biplane Simpson rule). The heart rate is determined from ECG. CONCLUSION: Two-dimensional echocardiography during pacing is a useful tool in the detection of coronary artery disease. Because of its safety and ease of repeatability noninvasive pacing stress echo can be the first-line stress test in patients with permanent pacemaker. The force-frequency can be defined as up- sloping (normal) when the peak stress pacing systolic pressure/end-systolic volume index is higher than baseline and intermediate stress values, biphasic with an initial up- sloping followed by a later down-sloping trend, or flat or negative when peak stress pacing systolic pressure/end-systolic volume index is equal or lower than baseline stress values. This approach is certainly highly feasible and allows a conceptually immaculate definition of contractility with prognostic usefulness, but its therapeutic implications remains to be established. Bowditch treppe, assessed with pacing stress, can be used to assess the optimal stimulation frequency and to optimise the patient's chronotropic response in programming rate-adaptive pacemakers.

Noninvasive assessment of left ventricular contractility by pacemaker stress echocardiography.

BACKGROUND: Estimating contractility of the left ventricle with noninvasive techniques is an important yet elusive goal. Positive inotropic interventions are mirrored by smaller end-systolic volumes and higher end-systolic pressures. An increased heart rate progressively increases the force of ventricular contraction (Bowditch treppe or staircase phenomenon). AIM: To assess the feasibility of a noninvasive estimation of force-frequency relation (FFR) during pacing stress in the echo lab in patients with permanent pacemaker (PM). METHODS: Transthoracic stress pacing echocardiography was performed in 26 patients with a permanent pacemaker (age 69+/-11 years; 21 men, 5 women). Seven patients had normal function at baseline and during stress ("normals"); eight had angiographically assessed coronary artery disease (three with and five without induced ischemia with stress echo); eleven patients had dilated cardiomyopathy (DC). To build the FFR, the force was determined at different steps as the ratio of the systolic pressure (SP, cuff sphygmomanometer)/end-systolic volume index (ESV, biplane Simpson rule/body surface area). Heart rate was determined from ECG. RESULTS: The absolute value of the FFR slope was highest in controls and lowest in DC patients. A flat-downsloping FFR was found in 12/19 patients but not for normals (p<0.01). CONCLUSIONS: Noninvasive pacemaker stress echocardiography (PASE) is a simple and efficient option to assess left ventricular (LV) contractility in patients with permanent pacemaker.