S. gallolyticus Aortic Valve Endocarditis with Mitral Valve Leaflet Aneurysm.

S. gallolyticus is one of the pathogenic agents of endocarditis, and mitral valve aneurysm is a rare but potentially devastating complication. We present a case of S. gallolyticus aortic valve endocarditis with concomitant anterior mitral valve leaflet aneurysm. Patient underwent surgery before aneurysm perforation, and postoperative course was uneventful. Time of surgery is crucial to avoid severe complications due to aneurysm rupture.

The worrisome liaison between left ventricular systolic dysfunction and mitral annulus calcification in type 2 diabetes without coronary artery disease: data from the SHORTWAVE study.

BACKGROUND AND AIM: Mitral annulus calcification (MAC) is a marker for coronary artery disease (CAD) and predicts poor outcome in the general population. No data are available on MAC in patients with type 2 diabetes. In these patients we assessed prevalence of MAC and the relation between MAC and left ventricular (LV) systolic function. METHODS AND RESULTS: As many as 386 patients with type 2 diabetes without CAD were studied with Doppler echocardiography. LV systolic dysfunction was defined by analyzing 120 healthy subjects. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (peak S') were considered as indexes of LV circumferential and longitudinal shortening and classified low if <89% and <8.5 cm/s, respectively (10th percentiles of controls). Patients who had MAC (107 = 28%) were older with longer duration of DM and were receiving more anti-hypertension medications than those who had not. At echocardiographic evaluation patients with MAC showed higher LV mass, larger left atrial volume (LAV), reduced sc-MS (88.4 ± 14.9 vs 92.6 ± 14.3%; p = 0.01) and peak S' (8.9 ± 2.2 vs 10.0 ± 2.0 cm/s; p < 0.001) than patients without MAC. Multiple logistic regression demonstrated older age (OR 1.03 [IC 1.01-1.06], p = 0.009), larger LAV (OR 1.19 [IC 1.11-1.28], p < 0.001) and combined reduction in sc-MS and peak S' (OR 3.00 [IC 1.57-5.72], p = 0.001) as independent factors associated with MAC. CONCLUSIONS: MAC is detectable in one fourth of patients with type 2 diabetes without CAD and is mostly related to LV systolic dysfunction expressed as combined impairment of LV circumferential and longitudinal fibers, independent of age and LAV.

The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists.

AIM: To identify differences between sexes in the clinical profile, use of resources, management and outcome in a large population of 'real world' patients with heart failure (HF). METHODS: A prospective cross-sectional survey was conducted on 2127 consecutive patients (47% women) admitted with HF to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000. RESULTS: Women were older, had a higher prevalence of atrial fibrillation, and more frequently a hypertensive or valvular aetiology. Females were admitted more frequently in Medical than in Cardiology Departments. The rate of invasive and non-invasive procedures was lower in women than in men, slightly higher if managed by cardiologists. Women were less frequently prescribed ACE-inhibitors, amiodarone, and spironolactone, and more frequently prescribed digoxin. In-hospital mortality was similar, without difference between health-care providers. A 6-month follow-up was performed in 56.4% of the cases in both setting, but less frequently in women. Event rates were similar with nearly half of patients re-hospitalised at least once. CONCLUSION: The 'real' HF woman has generally a more severe disease; she is an old lady who is more frequently hospitalised in a medical unit, receives few diagnostic, and cardiovascular procedures and pharmacological therapy, has a relatively low probability of dying in hospital, but a high likelihood of requiring readmission.

[Risk of sudden death in heart failure patients]. / Rischio aritmico nei pazienti con scompenso cardiaco cronico.

Sudden death is one of the more important cause of mortality in patients with chronic heart failure. The highest risk occurs among patients with less severe functional impairment, whereas patients in NYHA class IV usually die of progression of heart failure. Predictors of sudden death have been evaluated. Nevertheless, current methods of risk stratification for sudden death are still inadequate, especially in patients with advanced heart failure. Low left ventricular ejection fraction is widely used for the risk stratification, but it lacks of sensitivity and specificity in distinguishing patients with an increased arrhythmic mortality from those with an increased mortality due to pump failure. Unsustained ventricular tachycardia and inducibility at electrophysiological study may help identifying high-risk patients, requiring more aggressive therapy, as the ICD implantation. Heart rate variability and baroreflex sensitivity analysis have been utilized to obtain information on autonomic modulation, but with uncertain conclusion on the identification of high-risk patients. Increased QT dispersion, the presence of T-wave alternans and abnormal signal-averaged electrocardiography have also been proposed, but, up-to-now, any of these parameters showed a strong predictor power. In conclusion, our capability to identifying heart failure patients at risk for arrhythmic death is still far from being satisfactory.

Functional and psychological recovery during intensive hospital rehabilitation following cardiac surgery in the elderly.

UNLABELLED: The recovery process in the elderly after cardiac surgery is influenced not only by clinical cardiac conditions, but also by comorbidity, cognitive decline and disability. We evaluated the relationship between clinical objective and self-perceived factors and their influence on functional recovery in 204 consecutive, over-70s pts who were admitted into an intensive hospital rehabilitation program following cardiac surgery. The variables taken into consideration were: comorbidity (Charlson index), length of hospital stay and complications in cardiac surgery and rehabilitation, disability (nursing needs score index), functional status (6-min walking test), left ventricular EF, number of training sessions, self-perceived health status (EuroQol questionnaire), emotional impairment (anxiety/depression, CBA-2.0/interview). RESULTS: Functional capacity: the distance walked was 198 +/- 103 m at admission and 287 +/- 121 m at discharge (p < 0.0001). Only the nursing needs score index resulted as a weak, independent predictor of the distance walked at admission (r2 = 0.14, p < 0.001, beta = 0-.21), which (beta = 0.49), together with complications during rehabilitation (beta = -0.15), self-perceived health status at discharge (beta = 0.15) and number of training sessions (beta = 0.20), was independently correlated with the distance walked at time of discharge (r2 = 050, p < 0.0001). Patients mood: anxiety correlated with depression. Emotional scores did not correlate with functional measures. Patients self-perceived health status: only the nursing needs score index was a weak, independent predictor of well-being at entry (r2 = 0.15, p < 0.0001, beta = -0.29), which, in turn, was the only predictor of perception at discharge (r2 = 0.33, p < 0.0001, beta = 0-.42). CONCLUSIONS: In an intensive hospital rehabilitation program following cardiac surgery in patients over 70 a) there was no correlation between clinical and psychological variables; b) anxiety and depression were associated, but neither influenced the recovery process nor correlated to health status perception; c) functional impairment was strongly influenced by nursing needs which also affected the self-perceived health status; d) both functional and perception recovery were influenced by disability at time of admission and reacted positively after rehabilitation.

[Educating and communicating: non-pharmacologic treatment for patients with chronic heart failure?]. / Educare e comunicare: terapie non farmacologiche per il paziente con scompenso cardiaco cronico?

Chronic heart failure shows an increasing prevalence and extremely high rate of both hospital admission and readmission. Thus, in recent years there has been a growing interest in the development of more effective strategies for disease management. The existing literature shows programs involving multidisciplinary teams, specialized clinics, that employ a systematic approach and provide continuity of care, frequently involving a specialized nurse dedicated to comprehensive management. These experiences reported a favourable effects on clinically relevant outcome, including readmission, quality of care and cost of care. A recent randomized trial conducted by Krumholtz and colleagues emphasises the importance of patient's education and support intervention, without medical management components. This model was effective in reducing readmissions and in-hospital costs. On the basis of these data, patients education and support should be considered a "non-pharmacological therapy" for heart failure patients.

Your cardiac patient wants to become a mother. Risk considerations and advice Part I--your cardiac patient asks advice on a possible pregnancy.

In this part, the risks and complications of pregnancy in women with active or corrected, congenital or acquired heart disease are reviewed, in order to allow individual counseling on a possible pregnancy or treatment recommendations on contraception.

Platelet function in childhood migraine.

Platelet function in vitro and in vivo (ADP-induced platelet aggregation, circulating platelet aggregates, beta-thromboglobulin plasma levels) has been studied in children with common migraine, in headache-free intervals. Migraine patients demonstrated increased circulating platelet aggregates when compared with controls. Moreover, two of ten patients had pathological beta-thromboglobulin levels. These data indicate that in some children with migraine there is an abnormality of platelet function during headache-free periods.

[Platelet aggregation in vasomotor headache]. / L'aggregazione piastrinica nelle cefalee vasomotorie.

Employing optical density methods, platelet aggregation in response to increasing concentration of ADP was tested in 24 patients with migraine and 15 controls. The migraine patients don't demonstrate platelet hyperaggregability when compared with controls. Platelet aggregate ratio (P.A.R.) was measured in 13 patients and 15 controls by the method of Wu and Hoak: a significant difference was found between and controls. The hyperaggregability found here, even if only for the P.A.R., may help explain the increased incidence of stroke and heart attack in migraine patients that has been reported elsewhere.