Two-dimensional echocardiographic recognition of papillary muscle fibrosis in pediatric patients

Two-dimensional echocardiographic examinations were performed in seven infants with anomalous origin of the left coronary artery from the pulmonary artery (ALCA), in one infant with myocardial infarction and left main coronary obstruction, and in eight with critical valvar aortic stenosis (AS). Comparative qualitative echo density assessment demonstrated that each infant had a marked increase in the echo density of one or both left ventricular papillary muscles. The increased echo density was considered to represent fibrosis and scar formation as a result of ischemia and infarction. Pathologic proof of excessive fibrosis of the papillary muscles was obtained in three cases. In an additional case, calcification of the papillary muscle was noted on fluoroscopic examination. The echocardiographic appearance of papillary muscle fibrosis provides a useful indicator of severe subendocardial ischemia in patients with either critical AS or ALCA.     

Prospective, randomized evaluation of thrombectomy prior to percutaneous intervention in diseased saphenous vein grafts and thrombus-containing coronary arteries

OBJECTIVES: We sought to determine whether routine thrombectomy prior to stent implantation in diseased saphenous vein grafts (SVGs) and thrombus-containing native coronary arteries would reduce peri-procedural myonecrosis and subsequently enhance event-free survival. BACKGROUND: Percutaneous coronary intervention in diseased SVGs and thrombotic native coronary arteries is complicated by a high rate of peri-procedural myocardial infarction (MI). Thrombectomy prior to intervention may enhance the safety of intervention and improve early and late outcomes in these high-risk patients. METHODS: At 60 centers in the U.S. and Canada, 797 patients with 839 diseased SVGs or thrombus-containing native coronary arteries were prospectively randomized to stent implantation with versus without prior thrombectomy with the X-SIZER device (ev3, Plymouth, Minnesota). RESULTS: Peri-procedural MI occurred in 15.8% of patients assigned to the X-SIZER device compared with 16.6% of control patients (p = 0.77), although the rate of large MI (pre-specified as the development of new pathologic Q waves or creatine phosphokinase-MB isoenzyme elevation >8 x upper limits of normal) was reduced with X-SIZER device use from 9.6% to 5.5% (multivariate risk ratio 0.35 [95% confidence interval 0.18 to 0.66], p = 0.002). Major adverse cardiac events (cardiac death, MI, or repeat target vessel revascularization) occurred in 16.8% of X-SIZER patients versus 17.1% of control patients at 30 days (p = 0.92), and in 31.3% of X-SIZER patients versus 28.2% of control patients at 1 year (p = 0.35). CONCLUSIONS: Thrombectomy with the X-SIZER device prior to stent implantation in high-risk diseased SVGs and thrombus-containing native coronary arteries may reduce the extent, but not the occurrence, of myonecrosis. Early and late event-free survival, however, were not improved by routine thrombectomy with this device.     

Are angiotensin II receptor blockers more efficacious than placebo in heart failure? Implications of ELITE-2. Evaluation of Losartan In The Elderly

In the light of the recent randomized controlled trials in chronic heart failure, it is now commonly assumed that treatment with an angiotensin-receptor blocker (ARB) is equivalent to treatment with an angiotensin-converting enzyme (ACE) inhibitor. We performed an imputed placebo analysis using previous placebo-ACE inhibitor trials and the current ACE inhibitor-ARB comparison studies, which shows that ARBs may not even be superior to placebos, let alone an ACE inhibitor.     

Reversible metabolic myopathy in biotinidase deficiency: its possible role in causing hypotonia

Summary A 5-year-old girl diagnosed with biotinidase deficiency at 9 months of age demonstrated limb and axial hypotonia which improved on biotin therapy. In this patient, electromyographic (EMG) studies prior to treatment were compatible with a mild myopathic process. Serial EMGs performed on biotin therapy demonstrated a gradual resolution of the myopathy. This is the first documented case of a reversible myopathy in a patient with biotinidase deficiency, which may contribute to the clinical finding of hypotonia.     

Preclinical evaluation of lovastatin

Administration of lovastatin to animals at high dosage levels produces a broad spectrum of toxicity. This toxicity is expected based on the critical nature of the target enzyme (HMG CoA reductase) and the magnitude of the dosage levels used. The information reviewed in this paper demonstrates that these adverse findings in animals do not predict significant risk in humans. The reason for this derives from the fact that all the available evidence suggests that the adverse effects observed are produced by an exaggeration of the desired biochemical effect of the drug at high dosage levels. The presence of clear and high no-effect doses for these toxic effects along with the fact that most of the changes observed are clearly mechanism-based (directly attributable to inhibition of mevalonate synthesis) indicate that it is unlikely that similar changes will be observed at the therapeutic dosage levels in humans. This hypothesis is supported by the extensive human safety experience described by Tobert in the following report.