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.

Endothelial progenitor cells mobilization after maximal exercise according to heart failure severity.

BACKGROUND: Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure (CHF). Patients with CHF are characterized by impaired vasodilation and inflammation of the vascular endothelium. They also have low levels of endothelial progenitor cells (EPCs). EPCs are bone marrow derived cells involved in endothelium regeneration, homeostasis, and neovascularization. Exercise has been shown to improve vasodilation and stimulate the mobilization of EPCs in healthy people and patients with cardiovascular comorbidities. However, the effects of exercise on EPCs in different stages of CHF remain under investigation. AIM: To evaluate the effect of a symptom-limited maximal cardiopulmonary exercise testing (CPET) on EPCs in CHF patients of different severity. METHODS: Forty-nine consecutive patients (41 males) with stable CHF [mean age (years): 56 ± 10, ejection fraction (EF, %): 32 ± 8, peak oxygen uptake (VO2, mL/kg/min): 18.1 ± 4.4] underwent a CPET on a cycle ergometer. Venous blood was sampled before and after CPET. Five circulating endothelial populations were quantified by flow cytometry: Three subgroups of EPCs [CD34+/CD45-/CD133+, CD34+/CD45-/CD133+/VEGFR2 and CD34+/CD133+/vascular endothelial growth factor receptor 2 (VEGFR2)] and two subgroups of circulating endothelial cells (CD34+/CD45-/CD133- and CD34+/CD45-/CD133-/VEGFR2). Patients were divided in two groups of severity according to the median value of peak VO2 (18.0 mL/kg/min), predicted peak VO2 (65.5%), ventilation/carbon dioxide output slope (32.5) and EF (reduced and mid-ranged EF). EPCs values are expressed as median (25th-75th percentiles) in cells/106 enucleated cells. RESULTS: Patients with lower peak VO2 increased the mobilization of CD34+/CD45-/CD133+ [pre CPET: 60 (25-76) vs post CPET: 90 (70-103) cells/106 enucleated cells, P < 0.001], CD34+/CD45-/CD133+/VEGFR2 [pre CPET: 1 (1-4) vs post CPET: 5 (3-8) cells/106 enucleated cells, P < 0.001], CD34+/CD45-/CD133- [pre CPET: 186 (141-361) vs post CPET: 488 (247-658) cells/106 enucleated cells, P < 0.001] and CD34+/CD45-/CD133-/VEGFR2 [pre CPET: 2 (1-2) vs post CPET: 3 (2-5) cells/106 enucleated cells, P < 0.001], while patients with higher VO2 increased the mobilization of CD34+/CD45-/CD133+ [pre CPET: 42 (19-73) vs post CPET: 90 (39-118) cells/106 enucleated cells, P < 0.001], CD34+/CD45-/CD133+/VEGFR2 [pre CPET: 2 (1-3) vs post CPET: 6 (3-9) cells/106 enucleated cells, P < 0.001], CD34+/CD133+/VEGFR2 [pre CPET: 10 (7-18) vs post CPET: 14 (10-19) cells/106 enucleated cells, P < 0.01], CD34+/CD45-/CD133- [pre CPET: 218 (158-247) vs post CPET: 311 (254-569) cells/106 enucleated cells, P < 0.001] and CD34+/CD45-/CD133-/VEGFR2 [pre CPET: 1 (1-2) vs post CPET: 4 (2-6) cells/106 enucleated cells, P < 0.001]. A similar increase in the mobilization of at least four out of five cellular populations was observed after maximal exercise within each severity group regarding predicted peak, ventilation/carbon dioxide output slope and EF as well (P < 0.05). However, there were no statistically significant differences in the mobilization of endothelial cellular populations between severity groups in each comparison (P > 0.05). CONCLUSION: Our study has shown an increased EPCs and circulating endothelial cells mobilization after maximal exercise in CHF patients, but this increase was not associated with syndrome severity. Further investigation, however, is needed.

Clinical characteristics and long-term clinical course of patients with Brugada syndrome without previous cardiac arrest: a multiparametric risk stratification approach.

AIMS: Risk stratification in Brugada syndrome (BrS) still represents an unsettled issue. In this multicentre study, we aimed to evaluate the clinical characteristics and the long-term clinical course of patients with BrS. METHODS AND RESULTS: A total of 111 consecutive patients (86 males; aged 45.3 ± 13.3 years) diagnosed with BrS were included and followed-up in a prospective fashion. Thirty-seven patients (33.3%) were symptomatic at enrolment (arrhythmic syncope). An electrophysiological study (EPS) was performed in 59 patients (53.2%), and ventricular arrhythmias were induced in 32 (54.2%). A cardioverter defibrillator was implanted in 34 cases (30.6%). During a mean follow-up period of 4.6 ± 3.5 years, appropriate device therapies occurred in seven patients. Event-free survival analysis (log-rank test) showed that spontaneous type-1 electrocardiogram pattern (P = 0.008), symptoms at presentation (syncope) (P = 0.012), family history of sudden cardiac death (P < 0.001), positive EPS (P = 0.024), fragmented QRS (P = 0.004), and QRS duration in lead V2 > 113 ms (P < 0.001) are predictors of future arrhythmic events. Event rates were 0%, 4%, and 60% among patients with 0-1 risk factor, 2-3 risk factors, and 4-5 risk factors, respectively (P < 0.001). Current multiparametric score models exhibit an excellent negative predictive value and perform well in risk stratification of BrS patients. CONCLUSIONS: Multiparametric models including common risk factors appear to provide better risk stratification of BrS patients than single factors alone.

Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure.

AIM: Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure. METHODS: We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry. RESULTS: Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn. CONCLUSION: Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.

Post mortem coronary angiographic visualization of a rare sinus node artery anatomical variant.

The incidence of sinoatrial artery variants and their significance have been repeatedly reported in the literature. Herein we describe a rare post mortem angiographic finding which concerns a unique and previously unreported case where the sinus node artery had an abnormal origin from the proximal conus artery. Although it was asymptomatic, any possible involvement with invasive or surgical procedures and its clinical consequences should be considered.

Complex interventional procedures for the management of early postoperative left main coronary artery embolism after bioprosthetic aortic valve insertion.

The incidence of calcified debris coronary embolism after aortic valve replacement (AVR) with a bioprosthesis is a rare but potentially life-threatening condition. We sought to describe a case of immediate postoperative left main coronary artery embolism, resulting to severe acute coronary syndrome and cardiogenic shock, after aortic valve surgery due to severe aortic valve stenosis, with the use of bioprosthesis. Complex interventional procedures and possible diagnostic challenges are being described.

Clinical outcome and angiographic results with novel polysulfone polymer coating paclitaxel eluting stent in real-world clinical practice: a clinical centre registry.

BACKGROUND: The Intek-Apollo stent (Switzerland) employs a polysulfone polymer coating which has demonstrated low interaction with blood and high thrombo-resistance. The aim of this study was to assess the clinical and angiographic outcomes after Intek-Apollo stent utilisation in a real-world setting. MATERIAL/METHODS: A total of 130 patients (77.7% males) were enrolled with 174 lesions in native coronary arteries (92.4%), saphenous vein grafts (7.5%) and in-stent restenosis (6.3%). Indications for stenting were stable coronary artery disease (CAD) 52.3%, acute coronary syndrome (ACS) 37.7% and STEMI 10%. Clinical follow-up and coronary angiography (after symptoms occurrence or positive stress test) was performed at 6 and 12 months.The primary end points were target lesion revascularization (TLR) and target vessel revascularization (TVR), while secondary end points were major adverse cardiac events (MACE) during the follow-up period. RESULTS: The mean age of patients included was 61.62±11.13 years. Complex lesions treatment (ostial, bifurcation) reached 13.7%. Mean stenosis diameter was 83.52±10.5%. Reference vessel diameter was 2.85±0.39 mm with a mean lesion length of 14.66±4.5mm. Average stent size was 2.93±0.39mm × 16.6±4.73 mm. At 15±3 months, primary events included TLR (4.6%), TVR (4.6%) and MACE (2.3%). There was 1one myocardial infarction and no cardiac death). No incidence of early or late stent thrombosis was demonstrated. CONCLUSIONS: Intek-Apollo stent implantation is safe and efficient in a real world population. The unique properties of polysulfone polymer coating can effectively protect from late stent thrombosis and lead to reduced rates of TLR, TVR and MACE.

Contemporary practices in postcardiac arrest syndrome: the role of mild therapeutic hypothermia.

Out-of-hospital cardiac arrest remains a major cause of mortality and morbidity despite progress in resuscitative practices. The number of survivors with severe neurological impairment at hospital discharge is similarly dismal. Recently, much attention has been directed toward the use of mild therapeutic hypothermia in the care of comatose survivors with postcardiac arrest syndrome. Recent research suggests mild hypothermia lowers mortality and improves neurological outcome after successful treatment of cardiac arrest. The current 2005 updated guidelines of International Liaison Committee on Resuscitation and European Resuscitation Council recommend the utilization of mild induced hypothermia in postresuscitation treatment. Hypothermia induction in order to avoid the pathophysiological mechanisms of euthermia and hyperthermia and subsequent complications are briefly discussed. Cooling methods, potential side effects and questions regarding implementation of therapeutic hypothermia recommendations in every day clinical practice and future investigation are also addressed.

Uric acid elevation in atrial fibrillation.

INTRODUCTION: Uric acid is a cardiovascular risk marker associated with oxidative stress and inflammation. Recently, atrial fibrillation (AF) has been associated with inflammation and oxidative stress. We therefore investigated the association between AF and uric acid levels. METHODS: Consecutive patients with AF and healthy control subjects were screened. Demographic, clinical, and echocardiographic characteristics were carefully recorded. In each participant, uric acid levels and conventional inflammatory markers were determined. The final study population consisted of 45 patients with paroxysmal AF, 41 patients with permanent AF, and 48 control subjects. RESULTS: A significant variance in uric acid levels was evident between patients with paroxysmal AF (5.7 +/- 1.1 mg/dl), permanent AF (6.7 +/- 1.4 mg/dl), and control subjects (5.1 +/- 1.3 mg/dl) (p<0.001). After univariate analysis considering 2 groups (control, AF patients), the following variables were significantly associated with the presence of AF: age, hypertension, -blocker use, low left ventricular ejection fraction (LVEF), increased left atrial diameter, uric acid levels, and C-reactive protein (CRP) levels. After multivariate logistic regression analysis, only CRP was an independent predictor for AF (odds ratio, OR: 2.172). In a subgroup analysis, CRP (OR: 1.434) and LVEF (OR: 0.361) were independent predictors of paroxysmal AF, while CRP (OR: 3.048), uric acid (OR: 2.172), and LVEF (OR: 0.34) were predictors of permanent AF. CONCLUSIONS: There is an association between increased levels of uric acid and permanent AF. Also, uric acid elevation may be related to the burden of AF. Undoubtedly, larger studies should further examine this potential association.

Sensitivity and specificity of sodium channel blocking test in the diagnosis of Brugada syndrome.

The ECG features of Brugada syndrome are dynamic and frequently concealed. Sodium channels blockers are widely used to unmask the Brugada electrocardiographic (ECG) pattern. The sensitivity and specificity of I(Na) channel blocking test varies significantly. A negative I(Na) blocking test does not exclude the presence of a SCN5A mutation, which is responsible for the phenotype of Brugada syndrome. Herein, we describe the case of a 65-years-old asymptomatic male who underwent a I(Na) channel blocking test, seven years ago due to a type 2 ECG pattern (saddleback configuration) which failed to induce the diagnostic type 1 ECG pattern. Diagnostic considerations at a molecular level and their clinical relevance are being discussed.

Potential-guided versus anatomic-guided approach for slow pathway ablation of the common type atrioventricular nodal reentry tachycardia: a randomized study.

OBJECTIVE: The present study aimed to compare the effectiveness and safety of the potential- and the anatomic-guided approach for slow pathway ablation in patients with recurrent episodes of symptomatic common type atrioventricular (AV) nodal reentrant tachycardia. METHODS: Two hundred and twenty-eight patients were randomly assigned to undergo either a potential- (n=114, 47% men, mean age 52.85 +/- 14.04 years) or an anatomic-guided approach (n=114, 50% men, mean age 52.45 +/- 14.46 years) for radiofrequency ablation of the slow pathway.The mean duration of the follow-up period was 26.7 +/- 7.9 and 24.8 +/- 7.6 months in the potential- and anatomic- guided approach, respectively (P > 0.05). RESULTS: The success rate for slow pathway ablation was 100% in both ablative methods.The mean duration of atrial electrograms at the successful ablation sites of the potential- and the anatomic-guided approaches was 69 +/- 14 msec and 57 +/- 10 msec, respectively (P = 0.001).There were no significant differences between the potential- and the anatomic-guided approach regarding the duration of the procedure (121.13 +/- 56.83 vs. 109.93 +/- 57.12 min, P = 0.139), the duration of fluoroscopic exposure (6.12 +/- 3.32 vs. 6.64 +/- 3.33 min, P = 0.239) or the mean number of radiofrequency applications delivered (3.96 +/- 2.77 vs. 4.33 +/- 2.73, P = 0.311). Residual dual AV nodal pathway following successful ablation was observed in 9.6% of patients who underwent the potential-guided approach and in 23.7% of patients who underwent the anatomic method (P = 0.004). During followup, arrhythmia recurrence was observed in four patients (1.8%), two in each group (P > 0.05). CONCLUSIONS: The efficacy and safety of the slow pathway ablation is very high using either the potential- or the anatomic-guided approach.

Wide QRS complex supraventricular tachycardia with negative precordial concordance.

The authors describe the case of a 49-year-old man who experienced an episode of palpitations and dizziness. The results of 24-hour Holter monitoring demonstrated an episode of wide QRS complex regular tachycardia. During the electrophysiological study, a wide QRS complex tachycardia with negative precordial concordance was induced. A diagnosis of orthodromic atrioventricular re-entrant tachycardia involving a left lateral accessory pathway with left bundle branch aberration was made. This case represents a rare exception to the rule that negative precordial QRS concordance is diagnostic of ventricular tachycardia.

Predictors of atrial fibrillation recurrence in patients with long-lasting atrial fibrillation.

BACKGROUND: Limited data are available on the predictors of atrial fibrillation (AF) recurrence in patients with chronic AF. OBJECTIVES: To evaluate potential clinical, echocardiographic and electrophysiological predictors of AF recurrence, after internal cardioversion for long-lasting AF. METHODS: A total of 99 consecutive patients (63 men and 36 women, mean age 63.33+/-9.27 years) with long-standing AF (52.42+/-72.02 months) underwent internal cardioversion with a catheter that consisted of two defibrillating coils. Shocks were delivered according to a step-up protocol. Clinical follow-up and electrocardiographic recordings were performed on a monthly basis for a 12-month period or whenever patients experienced symptoms suggestive of recurrent AF. RESULTS: Ninety-three patients (93.94%) underwent a successful uncomplicated cardioversion, with a mean atrial defibrillation threshold of 10.69+/-6.76 J. Immediate reinitiation of AF was observed in 15 patients (15.78%) of whom a repeated cardioversion restored sinus rhythm in 13 cases. Early recurrence of AF (within one week) was observed in 12 of 93 patients (12.90%). At the end of the 12-month follow-up period, during which seven patients were lost, 42 of the 86 remaining patients (48.84%) were still in sinus rhythm. Multivariate regression analysis showed that left atrial diameter (OR 1.126, 95% CI 1.015 to 1.249; P=0.025) and mitral A wave velocity (OR 0.972, 95% CI 0.945 to 0.999; P=0.044) were significant and independent predictors of AF recurrence, whereas age, left ventricular ejection fraction and AF cycle length were not predictive of arrhythmia recurrence. CONCLUSION: The present study showed that the left atrial diameter and mitral A wave velocity are the only variables associated with AF recurrence after successful cardioversion.