Transcatheter closure of perimembranous ventricular septal defect: is the risk of heart block too high a price?

The late development of heart block in paediatric patients following device closure of a perimembranous ventricular septal defect may be a cause for concern.     

Transcatheter closure of atrial septal defects in the oval fossa: is the method applicable in small children?

We report our experience from 1996 through 1999, representing our initial experience with use of the Amplatzer device to close atrial septal defects. Of 46 patients taken to the catheter laboratory with the intention to close the defect, the device was permanently implanted in 40 (87%). They were aged between 1.4 and 71.8 years, with weights ranging from 7.8 to 90 kg. Both age and weight distributed into two peaks, demonstrating two different populations. The size of the devices, taking the biggest device if two were inserted, was between 9 and 30 mm. We underwent a short learning curve, but the time required for fluoroscopy, or the number of difficulties experienced, showed no connection with the size or age of the patient, nor the size of the defect itself. A suspicion that young age and small size would increase the risk and difficulties, and result in more interrupted procedures, could not be substantiated. In children no interruption was procedural. Our early experience, therefore, demonstrates that an experienced interventional team can use the Amplatzer occluder successfully to close atrial septal defects in patients of all ages and sizes, at least from 7.8 kg and up.     

Analyzing the association between aortic regurgitation and atherosclerosis: is pulse pressure a cause of atherosclerosis?

ABSTRACT

If pulse pressure, one of the mechanical stresses, is a risk factor for atherosclerotic cardiovascular disease, then atherosclerosis should be progressive in aortic regurgitation which is a representative disease with increased pulse pressure. This cross-sectional study included 1,149 patients. We examined the influence of aortic regurgitation on maximum intima-media thickness or brachial-ankle pulse wave velocity. The degree of aortic regurgitation was classified into 4 grades by color Doppler examination. There were 177 patients with aortic regurgitation. Pulse pressure was significantly higher in patients with aortic regurgitation than in those without it. On multiple regression analysis, aortic regurgitation was not found to be a significant independent variable for maximum intima-media thickness [standard partial regression coefficient: aortic regurgitation = grade 1, 0.011, P = 0.7635; aortic regurgitation ≥ grade 2, ?0.034, P = 0.3289] and brachial-ankle pulse wave velocity [standard partial regression coefficient: aortic regurgitation = grade1, ?0.043, P = 0.1197; aortic regurgitation ≥ grade2, 0.002, P = 0.9358] after adjusting for age, sex, body mass index, presence or absence of cardiovascular disease, antihypertensive treatment, diabetes, dyslipidemia, and smoking. These results found no causal association between aortic regurgitation and atherosclerosis, and were a contradiction to the opinion that pulse pressure was a risk factor of atherosclerosis.     

Liver transplantation in HIV-HCV coinfected candidates: what is the most appropriate time for evaluation?

Liver disease due to hepatitis C virus (HCV) represents an increasing cause of end-stage liver disease (ESLD) among HIV-infected individuals. Orthotopic liver transplantation (OLT) is currently the only hope for these patients. We analyzed the outcome of candidates who underwent OLT at our clinic between January 2003 and January 2004. Out of 366 HIV-HCV-coinfected individuals assessed, 16 (4%) were considered appropriate candidates for OLT. However, none of them has been transplanted so far. Death due to ESLD occurred in 4 (25%) of them within 3-8 months after evaluation was initiated. In conclusion, the mortality of HIV-HCV coinfected patients with ESLD waiting for OLT is high. An earlier assessment of HCV-HIV-coinfected candidates as well as improved strategies to make OLT available sooner after the assignment of patients to this procedure should be warranted.     

Response of narrow QRS tachycardia in a patient with surgical closure of atrial septal defect to atrial overdrive pacing: What is the mechanism?

A 57‐year old woman who had pericardial patch closure of ostium secundum atrial septal defect (ASD) at the age of 23 years presented with shortness of breath. Her echocardiogram showed no residual ASD, good biventricular function and normal pulmonary artery pressures.     

Methotrexate treatment in juvenile idiopathic arthritis: when is the right time to stop?

OBJECTIVES: To investigate whether prolonged methotrexate (MTX) treatment after induction of remission influences the subsequent duration of remission in patients with juvenile idiopathic arthritis (JIA), and to analyse the usefulness of myeloid related proteins 8 and 14 (MRP8/MRP14) as predictive markers for the stability of remission at the time when MTX is withdrawn. METHODS: Twenty five patients with oligoarticular and polyarticular JIA who received MTX to induce remission were followed up. MTX treatment was stopped after a mean of 3.8 months (group 1) or 12.6 months (group 2) after remission was documented. Differences in the number of relapses between these groups were looked for. Additionally, MRP8/MRP14 were analysed by ELISA in 22 patients. RESULTS: No difference was found in the number of relapses between patients with prolonged or early discontinued MTX treatment. Patients who were in stable remission had significantly lower MRP levels when MTX was discontinued than patients with relapses. With a cut off point for MRP8/MRP14 at 250 ng/ml, sensitivity and specificity were 100% and 70%, respectively. CONCLUSION: Longer duration of MTX treatment after induction of remission does not generally improve the status of remission in patients with JIA. Residual synovial inflammation seems to influence the rate of relapses after discontinuation of MTX treatment. MRP8/MRP14 indicate residual activity even in the absence of other laboratory or clinical signs of continuing inflammation. Normal serum concentrations of MRP8/MRP14 in clinical inactive arthritis may help to identify patients in whom MTX can be safely withdrawn after remission is achieved.     

Acute-phase proteins and Chlamydia pneumoniae infection: which one is more important in acute coronary syndrome?

Elevated levels of acute-phase proteins, a systemic marker for inflammation, predict coronary events; Chlamydia pneumoniae (C. pneumoniae) infection is associated with coronary atherosclerosis. The present study investigated whether inflammation or infection is involved in the pathogenesis of acute coronary syndrome (ACS) and which one has the more important role. The study group comprised 49 patients with angiographically diagnosed ACS, 48 cases of chronic coronary heart disease (CCHD), and 44 subjects with a normal coronary profile. The levels of serum C-reactive protein (CRP), fibrinogen and anti-C. pneumoniae IgG antibody were measured. The IgG antibody against C. pneumoniae was higher in the ACS and CCHD groups compared with the control group after adjusting for age and gender. The levels of CRP and fibrinogen were significantly increased in patients with ACS compared with controls and CCHD patients. Multiple stepwise logistic regression analysis revealed that C. pneumoniae IgG antibody is an independent risk factor for both ACS and CCHD (odds ratio 2.3 and 2.1, respectively), but the CRP level is a risk factor only for ACS (odds ratio 6.9). The inflammatory response, as indicated by acute-phase proteins, especially CRP, rather than C. pneumoniae infection, may contribute more to the clinical course of ACS.     

Primary adrenocortical carcinoma and delayed liver metastasis: is the surgery alone the right treatment? Case report

Adrenocortical carcinoma is a very rare tumor which can develop at any age in either sex, with an estimated incidence of 0.5-2 new cases per million per year. Only few cases of adrenocortical carcinoma are reported in the literature, probably because the differential diagnosis between malignant and benign mass is not easy. Surgery represents the treatment of choice for adrenocortical carcinoma and for its possible recidivisms. We report the case of a 36-year-old female patient affected by adrenocortical carcinoma, operated on in 1999 and re-operated on in 2002 for a liver metastasis of the same tumor, without any other treatment. This case may be interesting for its rarity as well as for the several difficulties of the diagnosis and the choice of treatment. In conclusion, the follow-up of these patients is mandatory due to the difficulties of diagnosis and curative surgery represents the best choice of treatment.     

Overinflation of balloon-expandable valves for transcatheter treatment of pure noncalcified native aortic regurgitation: How much oversizing is needed and achievable?

Transcatheter aortic valve implantation (TAVI) in noncalcified pure aortic valve regurgitation is challenging as dedicated valves are not widely available. We present a case series of four inoperable patients who underwent compassionate TAVI for this indication at our institution with a balloon-expandable valve. In this context, we analyzed the relevant technical aspects such as the need for larger oversizing of the transcatheter prosthesis and the safety and limits of valve overexpansion.     

Ventricular arrhythmias following coronary artery occlusion in rats: is the diabetic heart less or more sensitive to ischaemia?

Rhythm disorders are common complications in diabetic patients, due to their enhanced sensitivity to ischaemia. However, experimental studies are inconsistent, and both higher and lower vulnerability to injury has been reported. Our objectives were to compare susceptibility to ventricular arrhythmias in rats with prolonged duration of diabetes induced hy streptozotocin (45 mg/kg, i. v.), utilising two different models. Following 8 weeks, either anaestetised open-chest rats in vivo or isolated Langendorff-perfused hearts were subjected to 30 min regional zero-flow ischaemia induced by occlusion of LAD coronary artery. In addition, cardiac glycogenolysis and lactate production were measured. In open-chest rats, 90% of the controls exhibited ventricular tachycardia (VT) which represented 55.4% of total arrhythmias, whereby only 19.9% of arrhythmias occurred as VT in 44% of the diabetic rats (P < 0.05 vs controls). Duration of VT and ventricular fibrillation (VF) was reduced from 35.5 ± 11.1 and 224.8 ± 153.9 s in the controls to 4.8 ± 2.5 and 2.2 ± 0.2 s in the diabetics, respectively (P < 0.05). Accordingly, severity of arrhythmias (arrhythmia score, AS) was also lower in the diabetics (2.0 ± 0.38 vs 3.3 ± 0.3 in the controls; P < 0.05). In the isolated hearts, high incidence of VF was decreased in the diabetic hearts, and although VT occurred in almost all of the diabetic hearts, the duration of VT and VF was substantially shorter (61.5 ± 14.5 and 5.5 ± 0.5 s vs 221.5 ± 37 and 398.5 ± 55 s in the controls, respectively; P < 0.05). AS was reduced to 2.9 ± 0.12 from 4.1 ± 0.3 in the controls (P < 0.05). Postischaemic accumulation of lactate was lower in the diabetic than in the non-diabetic myocardium (20.4 ± 1.9 vs 29.5 ± 2.9 μmol/l/g w.wt.; P < 0.05). These results suggest that rat hearts with chronic diabetes, despite some differences in the arrhythmia profiles between the in vivo model and isolated heart preparation, are less sensitive to ischaemic injury and exhibit lower susceptibility to ventricular arrhythmias and reduced accumulation of glycolytic metabolites. Received: 3 April 2000, Returned for 1. revision: 9 May 2000, 1. Revision received: 5 July 2000, Returned for 2. revision: 7 August 2000, 2. Revison received: 11 September 2000, Returned for 3. revision: 27 September 2000, 3. Revision received: 13 October 2000, Accepted: 16 October 2000