Effect of statin pretreatment on the outcome of ST-segment elevation myocardial infarction in patients without prior history of coronary artery disease.

INTRODUCTION: Early statin treatment has beneficial effects on the prognosis after acute coronary syndromes. We investigated the impact of prior statin treatment on the outcome of patients without a prior history of coronary artery disease (CAD) who presented with ST-elevation myocardial infarction (STEMI) and were treated with thrombolysis. METHODS: The study enrolled 1032 consecutive patients who satisfied the above criteria. They were categorized into two groups, based on their prior statin treatment for at least 3 months before admission: the statin pretreatment group (n=124) and the statin-naïve group (n=908). All patients received high-dose statins during hospitalization and were prescribed statins after discharge. The primary outcome was the incidence of successful thrombolysis, as expressed by the percentage of patients with 50% ST-segment resolution and complete retrosternal pain resolution at 90 minutes. Secondary outcomes included reduction in high-sensitivity C-reactive protein (hs-CRP) and CK-MB levels, and in-hospital, short- and long-term cardiovascular mortality. RESULTS: ST-segment resolution 50% was observed in 63.7% of the statin-pretreatment group and in 49.1% of statin-naïve patients (p<0.01). Statin pretreatment was associated with lower hs-CRP and peak CK-MB levels (p<0.001). The statin-pretreatment group had lower 30-day mortality (5.6% vs. 12.3%, p<0.05), whereas no significant differences were detected in in-hospital or 3-year mortality. CONCLUSIONS: Prior statin treatment in patients without a history of CAD who present with STEMI is associated with successful thrombolysis, decreased systemic inflammation, a lesser degree of myocardial damage, and a possible reduction in short-term mortality.

Coexistence of mitral regurgitation and pulmonary regurgitation in an adult with surgically corrected tetralogy of Fallot.

In patients with corrected tetralogy of Fallot (TOF), progressive right ventricular volume overload from longstanding regurgitation of the pulmonary valve, results in severe late complications. The presence of additional major clinical conditions may aggravate the clinical status in these patients. We describe the case of a patient with coexistence of mitral and pulmonary regurgitation in the setting of corrected TOF who underwent successful surgical treatment.

Platypnea-orthodeoxia syndrome related to right hemidiaphragmatic elevation and a 'stretched' patent foramen ovale.

Patent foramen ovale (PFO), although frequently observed in adults, rarely causes adverse clinical consequences. The most serious among them, are cryptogenic strokes and less commonly significant hypoxia resulting from right-to-left shunt (RLS). Platypnea-orthodeoxia syndrome referring to abnormal oxygenation in the upright position has been correlated with reopening of foramen ovale and acute right-to-left intracardiac shunt. We report a case of platypnea-orthodeoxia syndrome secondary to the development of RLS through a 'stretched' PFO, in a patient admitted to the intensive care unit with severe respiratory failure requiring mechanical ventilation. The RLS was associated with right hemidiaphragmatic elevation, without an increased interatrial pressure gradient. The patient was successfully weaned from the ventilator after the percutaneous closure of PFO through a catheter-deployed double-umbrella device, presenting a full recovery.

A rare case of an inflammatory myofibroblastic tumor in a middle-aged female.

Inflammatory myofibroblastic tumors (IMTs) are distinct entities with specific characteristics immunohistochemically and molecularly. They are regarded as "intermediate malignancy" tumors of unknown etiology. We report a case of a 64-years-old woman with a fever and abdominal discomfort for 3 months; a computer tomography was performed indicating gastrointestinal stromal tumor. Histologically the lesion proved to be IMT of the abdomen.

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.

The effect of open-chest cardiac resuscitation on mitral regurgitant flow: an on-line transesophageal echocardiographic study in dogs.

INTRODUCTION: We sought to determine the effect of cardiac massage on a pre-existing regurgitant mitral valve during open-chest cardiopulmonary resuscitation (OCCPR) in an animal experiment. METHODS: Our study included 29 dogs that were used as experimental models. We anesthetized them and inserted a transesophageal echocardiographic (TEE) probe. Then we performed a transverse thoracotomy, attempting to produce acute mitral regurgitation (MR). In models that showed cardiac arrest we initiated OCCPR to restore cardiac function. The regurgitant area of mitral jet and left ventricular (LV) diameters and volumes were calculated before and during OCCPR using TEE. RESULTS: Ventricular fibrillation and/or electromechanical dissociation occurred in 13 animals (45%). In 4 models without preexisting MR, no additional regurgitation was detected during OCCPR, while in another 5 with preexisting MR we noticed a slight increase in the regurgitant flow. The regurgitant flow area changed from 0.62 +/- 1 cm2 before to 1.1 +/- 0.36 cm2 during OCCPR (p<0.008). In the 4 animals that had severe damage to the mitral apparatus after the attempts, the regurgitant flow increased from 4.01 +/- 0.93 cm2 to 7.7 +/- 2.6 cm2 (p<0.002). The LV transverse diameter decreased from 4.39 +/- 0.62 cm to 1.54 +/- 0.5 cm and its volume from 60.5 +/- 7.14 cm3 to 17.02 +/- 4.14 cm3 (both p<0.001), thus showing the effectiveness of OCCPR. CONCLUSIONS: Given the presence of preexisting mitral regurgitation, direct cardiac massage during OCCPR would probably be less effective than expected, because of an increase in the amount of the regurgitant.

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.