AFP role in predicting recurrence of hepatocellular carcinoma after living donor liver transplantation in HCV patients.

HCC is one of the leading causes of death worldwide. Liver transplantation including living donor transplantation is the best available treatment. We have analyzed our experience with LDLT in patients with HCC and HCV in order to determine if alpha feto-protein (AFP) is a better predictor of recurrence than the tumor burden. We have identified all patients with HCV related liver disease and HCC who have undergone LDLT in one center during the period from December 2000 to December 2014. Outcomes from the prospective database were compared for patients who met Milan criteria (single tumor ≤5 cm, maximum of 3 total tumors with none >3 cm) or not. Uni- and multi-variable analyses of factors influencing recurrence free survival (RFS) were performed. A total of 142 patients with HCC and HCV associated liver disease underwent LDTL during the study period. RFS was 96.4% at 1 years, 91.8% at 3 years and 91.8% at 5 years. Gender, model for End-Stage Liver disease (MELD), pre-transplant therapy, AFP level, tumor number, total tumor size were predictors of recurrence on univariable analysis. On multivariable analysis MELD score (Hazard ratio (HR) 1.16) and Log10 AFP (HR 3.14) were predictors of RFS. In the ROC curve analysis with an AUC of 0.76 the optimal cut-off value of AFP was 26ng/mL. In conclusion MELD score and pre-transplant AFP predict recurrence after LDLT for HCC with HCV infection.

Effect of acute myocardial infarction on cholesterol ratios.

OBJECTIVE: In patients with acute myocardial infarctions (MIs), cholesterol levels are no longer valid after 24 h from presentation because acute MI causes a rapid decline in serum levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol. The objective of this study was to evaluate the effect of acute MI on the total cholesterol/HDL cholesterol ratio and the LDL cholesterol/HDL cholesterol ratio. METHODS: The study consisted of 45 patients who were admitted to the hospital with acute MIs. Serum levels of total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides were determined on day 1 post-MI and day 4 post-MI. The total cholesterol/HDL cholesterol ratio and the LDL cholesterol/HDL cholesterol ratio were calculated. Serum lipid levels and cholesterol ratios were compared between day 1 post-MI and day 4 post-MI. RESULTS: From day 1 post-MI to day 4 post-MI, the mean (+/- SD) serum levels of total cholesterol (188.4 +/- 52.5 vs. 170.5 +/- 57.2 mg/dL, respectively; p = 0.01), LDL cholesterol (120.3 +/- 48.9 vs. 105.9 +/- 43.0 mg/dL, respectively; p = 0.009), and HDL cholesterol (45.0 +/- 18.5 vs 39.3 +/- 16.1 mg/dL, respectively; p < 0.001) decreased, but the mean serum level of triglycerides (119.2 +/- 81.2 vs 149.3 +/- 68.3 mg/dL, respectively; p = 0.006) increased. The cholesterol ratios, however, remained unchanged between day 1 post-MI and day 4 post-MI. The total cholesterol/HDL cholesterol ratio was 4.59 +/- 1.84 on day 1 post-MI and 4.67 +/- 1.77 on day 4 post-MI (change not significant). The LDL cholesterol/HDL cholesterol ratio was 2.96 +/- 1.58 on day 1 post-MI and 2.99 +/- 1.44 on day 4 post-MI (change not significant). CONCLUSION: Acute MI does not affect the cholesterol ratios. Therefore, when the absolute levels of serum cholesterol are no longer valid (beyond 24 h after an MI), the cholesterol ratios still could be useful for cholesterol risk assessment in patients with acute MIs.

Prognostic value of serum cardiac troponin I in ambulatory patients with chronic renal failure undergoing long-term hemodialysis: a two-year outcome analysis.

OBJECTIVES: We sought to evaluate the prognostic value of cardiac troponin I (cTnI) in asymptomatic, ambulatory patients with chronic renal failure treated with long-term hemodialysis. BACKGROUND: Smaller, short-term follow-up studies on this subject have given conflicting results. METHODS: A total of 126 ambulatory patients with chronic renal failure treated with long-term hemodialysis were followed for two years for all-cause mortality, cardiac mortality, all-cause hospital admissions and cardiac hospital admissions. Serum cTnI was measured before dialysis at the time of study entry. RESULTS: One hundred two patients had normal serum levels of cTnI (< or =0.03 ng/ml) and 24 patients had elevated levels (0.015 +/- 0.007 vs. 0.053 +/- 0.029 ng/ml, p < 0.0001). No significant difference in all-cause mortality (20 vs. 4 deaths), cardiac mortality (4 vs. 1 death), all-cause hospital admissions (1.74 +/- 1.72 vs. 1.25 +/- 1.19 admissions/patient) or cardiac admissions (0.52 +/- 0.89 vs. 0.33 +/- 0.76 admissions/patient) was present between the patients with normal cTnI levels and those with elevated cTnI levels. Serum cTnI was not significantly different between patients who died versus those who survived (0.022 +/- 0.019 vs. 0.022 +/- 0.021 ng/ml). Serum cTnI was not an independent predictor of all-cause mortality, cardiac mortality, all-cause admissions or cardiac admissions. Age (older) and serum albumin (lower) were independent predictors of all-cause mortality, whereas a history of myocardial infarction was an independent predictor of cardiac mortality. Serum sodium (lower) was an independent predictor of all-cause hospital admissions, whereas hypertension and previous myocardial infarction were independent predictors of cardiac admissions. The best predictors of the time to death were age (older) and serum sodium level (lower), irrespective of the serum cTnI levels. CONCLUSIONS: Cardiac troponin I has a limited role in predicting mortality and hospital admissions in asymptomatic patients with chronic renal failure treated with long-term hemodialysis.

Anomalous circumflex coronary artery: benign or predisposed to selective atherosclerosis.

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly and is usually considered benign. Although several researchers in the past believed that aberrancy predisposes this vessel to accelerated atherosclerosis, this could not get wide acceptance owing to lack of convincing data. To examine the suggestion that atherosclerosis affects the anomalous circumflex artery more severely, the authors reviewed the clinical and angiographic features of patients with this anomaly identified from 2,684 coronary angiography procedures performed between January 1998 and March 2000 at their institution. The degree of atherosclerotic narrowing in the anomalous artery was compared with that in other coronary arteries in the same patient as well as in the nonanomalous circumflex arteries in controls. For comparison 3 control subjects were selected for each patient with anomalous circumflex artery, matched by age, sex, and clinical presentations. The results showed earlier and greater degree of atherosclerotic narrowing of the anomalous artery as compared to the other coronary arteries in the same patients as well as to nonanomalous circumflex arteries of age- and gender-matched control subjects with similar clinical characteristics. However, this predilection for atherosclerosis was evident only in anomalous vessels arising from the right side and pursuing a retroaortic course. The anomalous artery was responsible for myocardial infarction in 3 patients, all of whom were 60 years or older. Two of the patients with this anomaly and myocardial infarction underwent successful angioplasty with stent placement for symptomatic relief.

Age-related differences in the use of cardiac medications in patients with coronary artery disease.

BACKGROUND: Benefits of aspirin and beta-blocker use in patients with coronary artery disease and angiotensin-converting enzyme (ACE) inhibitors in those with left ventricular systolic dysfunction are well documented in all age groups. OBJECTIVE: To investigate whether aspirin, beta-blockers, and ACE inhibitors are equally used in geriatric (> or =65 years) versus younger (<65 years) patients with coronary artery disease. SETTING: University-affiliated major academic hospital. METHODS: Records of 402 patients with coronary artery disease were analyzed for use of aspirin, beta-blockers, and ACE inhibitors. One hundred thirty patients with contraindications to use of these agents were excluded. RESULTS: Of 272 study patients, 85% were using aspirin and 71% beta-blockers. Among the patients with left ventricular systolic dysfunction, 79% were using ACE inhibitors. One hundred forty-seven patients were of geriatric age, whereas 125 were of younger age. No significant difference in the use of aspirin (82% versus 89%, P = 0.10), beta-blockers (71% versus 70%, P = 0.85), or ACE inhibitors (86% versus 69%, P = 0.13) was found between geriatric and younger patients. This lack of difference in use of cardiac medications between geriatric and younger patients persisted on gender-based subgroup analysis. On decade-of-age-based analysis, aspirin use was not equally distributed among all the decades of age (P < 0.005), but beta-blocker use was. CONCLUSION: Results of this study demonstrate equal use of aspirin, beta-blockers, and ACE inhibitors in geriatric versus younger patients with coronary artery disease. Aspirin use was not equally distributed among all the decades of age.

Atrial fibrillation associated with systemic lupus erythematosus and use of methylprednisolone.

Systemic lupus erythematosus is known to have cardiac manifestations consisting of pericarditis, myocarditis, endocarditis, and coronary vasculitis. Pericarditis is the most common cardiac manifestation of systemic lupus erythematosus. Myocarditis may be suspected in patients presenting with unexplained tachycardia, conduction disturbances, unexplained systolic dysfunction with or without heart failure, or arrhythmias. The development of arrhythmias in systemic lupus erythematosus could be secondary to pericarditis, myocarditis, or ischemia caused by coronary vasculitis. The development of atrial fibrillation in systemic lupus erythematosus is not commonly reported. There have been few reports on the patients developing atrial fibrillation after being started on methylprednisolone therapy. Described here is a case of the development of atrial fibrillation in a newly diagnosed 37-year-old patient with systemic lupus erythematosus who was started on intravenous methylprednisolone therapy.

Scleroderma pericardial disease presented with a large pericardial effusion--a case report.

Scleroderma pericardial disease is usually silent and benign. The incidence of pericardial involvement in scleroderma is about 50% according to autopsy results, but symptomatic pericarditis manifests in about 16% of patients with diffuse scleroderma and in about 30% of patients with limited scleroderma. The clinically evident pericardial effusion is rare in scleroderma, although it can be detected in about 41% of patients with echocardiography. In majority of the patients, the pericardial effusion is small and not associated with symptoms. The pericardial effusion manifests usually after the manifestation of the other clinical and serologic features of scleroderma. A case of scleroderma is reported that presented with a large pericardial effusion, which antedated the other clinical and serologic features of scleroderma. The pericardial involvement in scleroderma is reviewed.

Acute ventricular rate control in atrial fibrillation: IV combination of diltiazem and digoxin vs. IV diltiazem alone.

OBJECTIVE: To analyze the efficacy of an IV combination of diltiazem and digoxin vs IV diltiazem alone for acute ventricular rate control in patients with atrial fibrillation. DESIGN: Prospective, randomized, open-label study. PATIENTS AND METHODS: Fifty-two patients with atrial fibrillation and uncontrolled ventricular rates were randomized to receive either an IV combination of diltiazem and digoxin or IV diltiazem alone and were observed for 12 h. The successful rate control was defined as a ventricular rate < 100 beats per minute (bpm) persisting for 1 h or conversion to sinus rhythm. The loss of rate control was defined as an increase in the ventricular rate to > 100 bpm persistently for > 30 min or rebound to atrial fibrillation. RESULTS: In both treatment arms (n = 26 each), all patients achieved successful and comparable ventricular rate control at 12 h. The mean (+/- SD) time taken to achieve successful rate control was shorter in the combination arm (15 +/- 16 vs. 22 +/- 22 min). Six patients in the combination arm and 11 in the diltiazem-alone arm experienced episodes of loss of rate control. This loss in the combination arm was less than that in the diltiazem-alone arm (14 vs 39 episodes; p = 0.05). The loss of rate control per patient in the combination arm was also less than that in the diltiazem-alone arm (2.0 +/- 1.0 vs. 3.5 +/- 1.9 episodes per patient; p = 0.04). CONCLUSIONS: This study demonstrates that in patients with atrial fibrillation who have a rapid ventricular response, the IV combination of diltiazem and digoxin results in a more efficacious ventricular rate control with fewer fluctuations than that achieved by therapy with IV diltiazem alone.

Worsening of left ventricular diastolic dysfunction during exercise causes decreased exercise tolerance in hypertension.

BACKGROUND: Exercise tolerance is reduced in hypertension. Hypertension affects left ventricular (LV) diastolic filling by causing abnormal relaxation and decreasing compliance. HYPOTHESIS: This study was designed to determine whether worsening of LV diastolic dysfunction during exercise causes decreased exercise tolerance in hypertension. METHODS: Left ventricular diastolic filling parameters were examined at mitral valve by Doppler echocardiography at rest and at peak exercise in hypertensive patients and were compared with those of age- and gender-matched normotensive individuals. Treadmill exercise stress test was performed according to the Bruce protocol and the exercise time was recorded. RESULTS: Exercise time was significantly shorter in the hypertensive group than that in the normotensive group (320 +/- 29 vs. 446 +/- 38 s, p 0.03). The hypertensive group demonstrated abnormal relaxation pattern of diastolic mitral inflow at rest, which became pseudonormal at peak exercise (E/A velocity ratio, rest 0.86 +/- 0.06 vs. exercise 1.19 +/- 0.09, p < 0.001). The diastolic mitral inflow pattern remained normal at peak exercise in the normotensive group. The deceleration time and the pressure half time of early mitral inflow at peak exercise were significantly shorter in the hypertensive group than those in the normotensive group (deceleration time, 182 +/- 20 vs. 238 +/- 22 ms, p 0.02: pressure half time, 54 +/- 5 vs. 70 +/- 12 ms, p 0.01). CONCLUSIONS: This study demonstrates that reduced exercise tolerance in hypertension is associated with worsening of diastolic dysfunction during exercise consistent with an increase in left atrial pressure.

Nonatherosclerotic aneurysm of the left circumflex coronary artery presenting with accelerated angina pectoris: response to medical management--a case report.

Coronary artery aneurysm is defined as coronary dilatation with a diameter of more than 1.5 times the adjacent normal coronary artery. Most of the coronary aneurysms remain asymptomatic. More than 90% of coronary aneurysms are of atherosclerotic origin. Nonatherosclerotic coronary aneurysms are rare, and the majority of them are diffuse. Among the three major coronary arteries, the left circumflex artery is the least commonly involved. The management strategies for nonatherosclerotic coronary aneurysms are not clear, and each case should be managed on an individual basis depending on the clinical context. Here described is a case of a discrete nonatherosclerotic aneurysm of the left circumflex coronary artery in a 46-year-old man who presented with accelerated angina pectoris and was treated medically. The patient was free of symptoms on 2-year follow-up. The clinical perspectives of the nonatherosclerotic coronary aneurysm are discussed.

A left atrial paraganglioma patient presenting with compressive dysphagia.

Paragangliomas are rare neoplasms of neural crest origin arising in the chromaffin (pheochromocytoma) and chemoreceptor (chemodectoma) tissues. Only a few cases of paragangliomas have been reported in the heart. Most of the cardiac paragangliomas are located in, or adjacent to, the left atrium. The biological activity indicative of catecholamine production has rarely been shown in cardiac paragangliomas. Patients with cardiac paragangliomas may present with hypertension, or with various obstructive or compressive symptoms, depending on the location of the tumour. A left atrial paraganglioma compressing the esophagus causing dysphagia is presented. A 37-year-old female patient underwent work-up for dysphagia to solids. Transesophageal echocardiography showed the presence of a large mass in the dilated left atrium. The tumour was removed completely intact and was a benign noncatecholamine-secreting paraganglioma. The patient's dysphagia was relieved. The clinical perspectives of cardiac paraganglioma and cardiac dysphagia are discussed.

Painless limited dissection of the ascending aorta presenting with aortic valve regurgitation.

Aortic dissection is a medical emergency carrying high morbidity and mortality. Prompt diagnosis is sometimes difficult because of its varying presentations, but it is critical to the achievement of good clinical outcomes. This report describes 2 cases of painless aortic dissection that presented with aortic valve regurgitation. In both, the dissection was limited to the ascending aorta just distal to the aortic valve. These dissections were diagnosed by transthoracic and transesophageal echocardiography.

Elevation of serum cardiac troponin I in noncardiac and cardiac diseases other than acute coronary syndromes.

This study evaluated the role of serum cardiac troponin I as a biochemical marker for the diagnosis of acute coronary syndromes in the presence of noncardiac diseases. Diagnostic characteristics were examined in 102 consecutive patients who were found to have serum cardiac troponin I levels higher than the upper reference limit of 0.6 ng/mL. Of 102 patients with cardiac troponin I levels of >0.6 ng/mL, 35 did not have the final diagnoses of acute coronary syndromes (myocardial infarction or unstable angina) but had various other final diagnoses, including nonischemic dilated cardiomyopathy, muscular disorders, central nervous system disorders, HIV disease, chronic renal failure, sepsis, lung diseases, and endocrine disorders. The mean value of serum cardiac troponin I in the patients with diseases other than acute coronary syndromes was significantly lesser than in those with acute coronary syndromes (2.0+/-1.9 [SD] v. 24.7+/-28.2 ng/mL; P<.0001). There were significantly fewer histories of chest pain and prior myocardial infarction in patients with diseases other than acute coronary syndromes than in those with acute coronary syndromes (history of chest pain, 3 v. 48 patients [P<.001]; history of prior myocardial infarction, 0 v. 30 patients [P<.001]). In conclusion, elevated serum levels of cardiac troponin I, especially in the lower ranges, should be interpreted with caution, particularly in patients suffering from acute illnesses who lack other diagnostic features suggestive of acute coronary ischemic events.

Bifurcating aneurysm of the left main coronary artery involving left anterior descending and left circumflex arteries--a case report.

Coronary artery aneurysm is a rare coronary abnormality, usually diagnosed incidentally by coronary angiography. Major causes of coronary aneurysms include coronary ectasia, Kawasaki disease, and atherosclerosis. Most of the discrete coronary aneurysms are of atherosclerotic origin. The incidence of atherosclerotic coronary aneurysms is about 0.2%, and the left main coronary artery is the least frequently involved artery. Only a few cases of left main coronary artery aneurysm have been reported in the literature, and a left main coronary artery aneurysm involving the proximal segments of the left anterior descending and the left circumflex arteries has not been reported previously. The authors describe this finding in a man who presented with worsening exertional angina pectoris. Coronary angiography demonstrated an aneurysm of the distal left main coronary artery extending into the proximal segments of the left anterior descending and the left circumflex arteries. In addition, a significant flow-limiting atherosclerotic lesion was present in the proximal portion of the left anterior descending artery distal to the aneurysm.

Asymptomatic dissection of the ascending aorta: diagnosis by transesophageal echocardiography.

A young man with marfanoid habitus underwent transesophageal echocardiography to evaluate an aortic root abnormality visualized on transthoracic echocardiography. Transesophageal echo demonstrated a type A aortic dissection traversing across the right sinus of Valsalva but not involving the aortic valve, right coronary artery, or pericardial sac. The aorta was not dilated. This is apparently the first reported case of an asymptomatic and uncomplicated aortic dissection localized to the sinus of Valsalva.

Torsades de pointes: a case with multiple variables.

Torsades de pointes is a polymorphic ventricular tachycardia that displays a unique electrocardiographic feature of twisting of the mean electrical axis of QRS complexes around an isoelectric line on the surface electrocardiogram. It is associated with long QT syndrome and has many precipitating mechanisms, etiologic factors, and treatment options. This report presents a case of torsades de pointes that was precipitated by multiple factors and required many treatment modalities. The patient in this case exhibited features of both congenital and acquired types of long QT syndrome.

Increased regional and transmyocardial dispersion of ventricular repolarization in end-stage renal disease.

BACKGROUND: Approximately half of patients with end-stage renal disease die because of cardiac disease, and ventricular arrhythmias are the common terminal events. Increased dispersion of the repolarization phase of the myocardial action potential can predispose patients to ventricular tachycardia and fibrillation causing cardiac death. OBJECTIVE: To determine the existence of increased regional and transmyocardial dispersion of ventricular repolarization in end-stage renal disease. STUDY DESIGN: Case-control prospective study. PATIENTS AND METHODS: The QT dispersion and the interval between the peak of the T wave (Tp) and the end of the T wave (Te) on a surface electrocardiogram represent regional and transmyocardial dispersion in ventricular repolarization, respectively. The prehemodialysis QT dispersions and Tp-Te intervals of 94 consecutive patients with end-stage renal disease were determined and compared with those of age- and sex-matched healthy controls. RESULTS: Both the QT and the QTc dispersion were significantly higher in the end-stage renal disease group than in the control group (QT dispersion 46 +/- 17 ms [mean +/- SD] versus 26 +/- 16 ms, P < 0.001; QTc dispersion 51 +/- 20 ms versus 30 +/- 20 ms, P < 0.001). Similarly, both the corrected average Tp-Te and the corrected maximum Tp-Te intervals were significantly higher in the end-stage renal disease group than in the control group (corrected average Tp-Te interval 99 +/- 19 ms versus 87 +/- 19 ms, P = 0.023; corrected maximum Tp-Te interval 114 +/- 23 ms versus 103 +/- 23 ms, P = 0.023). CONCLUSIONS: Increased regional and transmyocardial dispersion of ventricular repolarization in end-stage renal disease was demonstrated. This increased dispersion may be a contributory factor in the high cardiac mortality in patients with end-stage renal disease.

Separate origins of all three major coronary arteries from the right sinus of Valsalva: a rare coronary artery anomaly.

The origination of all three major coronary arteries from three separate ostia in the right sinus of Valsalva is an exceedingly rare coronary anomaly. Few radiographic and clinical details of this anomaly are available in the literature. We describe this anomaly in a patient with acute myocardial infarction who remained asymptomatic until the 8th decade of her life. Atherosclerotic narrowing of the normally originating right coronary artery caused the acute myocardial infarction. Anomalous left anterior descending and left circumflex arteries were free of any significant obstruction.