Anomalous Right Coronary Artery Origin from Left Main Stem: Role of Cardio-Computed Tomography in the Diagnosis and Therapeutic Approach.

Anomalous coronary arteries (ACAs) are rare but potentially life-threatening abnormalities of coronary circulation. Most of the variants are benign; however, some may lead to myocardial ischemia and/or sudden cardiac arrest. We report the case of a 75-year-old male complaining of exertion chest discomfort. Admission electrocardiogram on presentation showed sinus bradycardia with a slight elevation of ST-T in inferior leads. Troponin levels, however, were normal. Coronary angiography showed an anomalous right coronary artery (RCA) originating from the left main stem without significant stenosis. Cardio-CT confirmed the anomalous origin of the RCA from the left main stem and showed its anomalous course between the aorta and the pulmonary artery. The patient was deemed a candidate for surgery and transferred to a cardiac surgery center. Only the exact definition of the anatomic and clinical features of ACAs may allow the identification of the most appropriate and effective treatment. Multislice computed tomography may play a fundamental role in the diagnosis and treatment of ACAs.

Fast 'wandering' Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning.

We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent 'migration' of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly 'wander' within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly 'wandering' cases.

Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry.

BACKGROUND: Left ventricular outflow tract obstruction (LVOTO) may complicate an episode of Takotsubo cardiomyopathy (TTC), potentially leading to cardiogenic shock. Beta-blockers are considered the most suitable treatment for such complication. AIM OF THE STUDY: The objective of this study was to evaluate the hemodynamic effects, safety, and feasibility of a selective beta-blocker (ß1) with a short half-life, esmolol, in subjects with a TTC episode. METHODS: Ninety-six consecutive patients with TTC were enrolled in a multicenter registry. The hemodynamic and echocardiographic effects of esmolol (0.15-0.3 mg/kg/min) were analyzed in nine consecutive patients with LVOTO. Clinical course of patients, hemodynamics, days of hospitalization, LV function, and adverse events at follow-up were recorded. RESULTS: Left ventricular outflow tract obstruction was present in 10 (10.4%) of 96 patients. Patients with LVOTO were older and had higher values of troponin-I at admission. LV ejection fraction at admission (36.1 ± 8.4%) significantly improved at discharge (51.4 ± 6.9%, P = 0.001). Among patients treated with esmolol infusion, LVOT pressure gradient before treatment was 47.6 ± 16.6 mmHg and after 18.2 ± 2.3 mmHg (P = 0.0091). Systolic blood pressure decreased from 123.8 ± 29.1 to 112.6 ± 12.7 mmHg (P = 0.1537). Mean hospital stay was 9 ± 2 days. No adverse events were observed during hospitalization and at follow-up. CONCLUSIONS: Esmolol infusion was temporally associated with reduction in intraventricular gradient and systemic blood pressure in patients with TTC and LVOTO. Further controlled studies are warranted to confirm these preliminary findings.

Pleiotropic effects of statin in therapy in heart failure: a review.

Clinical trials demonstrated that statin therapy is associated with a significant reduction in cardiovascular morbidity and mortality when used for either primary or secondary prevention of cardiovascular events. Several studies have shown that statins, having an important effect in the prevention of acute coronary syndromes, are also able to prevent heart failure (HF) in patients with coronary artery disease. This review summarizes the experimental and clinical evidence regarding the role of statins in the management of HF.

Inflammatory activation in an unselected population of subjects with atrial fibrillation: links with structural heart disease, atrial remodeling and recent onset.

Previous studies investigated circulating levels of C-reactive protein (CRP) mostly in subjects with paroxysmal atrial fibrillation (AF) and lone AF (LAF). We, therefore, aimed to investigate circulating levels of CRP in patients with new onset AF with particular regards to AF duration, even in the presence of structural heart disease (SHD). CRP levels were evaluated in 96 consecutive patients with new onset AF (50 with LAF and 46 with SHD, 41 with paroxysmal AF (PAF) (<7 days) and 55 persistent AF (>7 days). Patients with AF had higher CRP levels than controls (4.8 ± 6.99 vs. 1.59 ± 1.32 mg/L; p < 0.001). AF patients with SHD had higher CRP levels than LAF patients (7.08 ± 9.19 vs. 2.63 ± 2.47 mg/L; p < 0.01) and control subjects (vs. 1.59 ± 1.32 mg/L; p < 0.001): CRP levels in LAF patients were higher than in controls (p < 0.01). CRP levels were significantly increased in subjects with paroxysmal AF (6.67 ± 9.44 mg/L) with respect to those with persistent AF (3.54 ± 4.44 mg/L, p < 0.05) and controls (1.59 ± 1.32 mg/L, p < 0.001 vs. paroxysmal AF, p < 0.01 vs. persistent AF). Differences related to the presence of LAF and SHD remained significant even after multivariable regression analysis. CRP concentrations significantly correlated with left atrial size(r 0.23, p < 0.05). Increased CRP levels are detectable in patients with AF, proportional to atrial remodeling, recent onset of dysrhythmia and SHD.

Three-vessel coronary artery disease with multi-vessel proximal aneurysms.

We report the case of a 47-year-old man, referred for chest pain radiating to jaws associated with sweating. At coronary angiography, left anterior descending coronary artery was occluded with distal perfusion by collateral flow, and proximal coronary aneurysms involving proximal left circumflex (LCX) right coronary artery with diffuse coronary atherosclerosis were present. Coronary thrombosis was also present into LCX proximal aneurysm.

Acute phase proteins in patients with acute coronary syndrome: Correlations with diagnosis, clinical features, and angiographic findings.

BACKGROUND: C-reactive protein (CRP) plasma levels increase in patients with acute coronary syndrome (ACS). The role and implications of increased plasma concentrations of other acute phase proteins (APPs), such as alpha-1-antitrypsin (A1AT), alpha-1 glycoprotein (A1GP), haptoglobin (HG), ceruloplasmin (CP), and C3c and C4 complement fraction, in patients with ACS are still not completely defined. METHODS: A total of 218 consecutive patients with ACS were included in the study, 185 with acute myocardial infarction (AMI) and 33 with unstable angina (UA). In all patients, A1AT, A1GP, HG, CP, C3c and C4 complement fraction, and CRP were evaluated within 12 h after the onset of symptoms. Sixty-two patients with AMI underwent coronary angiography. RESULTS: APPs showed a significant correlation with CRP concentrations. Patients with AMI had higher concentrations of A1AT and HG than UA patients. Cholesterol levels were correlated with APPs in patients with AMI. Patients with three coronary vessel disease or LAD disease had significantly higher C3c concentrations. Coronary collateral flow was associated with higher A1GP and CP concentrations, and total coronary occlusion with A1AT and CP. CONCLUSIONS: APPs were correlated with CRP concentrations in subjects with ACS. The increase in APPs in patients with ACS seems to be linked to the entity of myocardial damage and coronary atherosclerotic burden.