Myocardial Hematoma Documented by Transthoracic Echocardiography After Sequential Coronary Artery Stenting

We report the case of a patient who deteriorated suddenly while undergoing endoluminal coronary artery reconstruction with multiple stents to the left anterior descending coronary artery. With the aid of transthoracic echocardiography, a pericardial effusion was noted; however, dissection of the ventricular wall due to a large myocardial hematoma was also identified. Emergency exploration with evacuation of the pericardial blood with coronary artery bypass graft surgery was successfully accomplished. We discuss the possible factors that could have been associated with this unforeseen complication and the potential benefit of transthoracic echocardiography in early recognition.     

Myocardial bridging increases the risk of coronary spasm

BACKGROUND: Myocardial bridging (MB) has been associated with cardiac events. Whether coronary spasm is one factor contributing to those events is unknown. HYPOTHESIS: This study investigated whether the likelihood of coronary spasm is increased in patients with MB. METHODS: A spasm-provocation test was performed by infusing acetylcholine into the left coronary artery in 114 Japanese patients with chest pain. The test result was defined as positive when the diameter of the coronary artery was reduced by > or = 50% and ST-segment changes were documented. Myocardial bridging was defined as a > 15% reduction in coronary arterial diameter during systole after intracoronary injection of nitroglycerin. RESULTS: Myocardial bridging was identified in 41 patients (36%) and was located in the mid-segment of the left anterior descending coronary artery (LAD) in all patients. Patients with MB experienced coronary spasm more frequently than patients without MB (MB+: 73%; MB-: 40%, p = 0.0006). Furthermore, among patients with a positive spasm-provocation test, coronary spasm occurred more frequently in the mid-segment of the LAD in patients with MB than in those without MB (MB+: 73%; MB-: 45%, p = 0.0259). Multivariate regression analysis demonstrated that MB was a predictor of coronary spasm (odds ratio: 3.478, p = 0.0088). CONCLUSIONS: These results suggest that MB increases the risk of coronary spasm and that coronary spasm may be the proximate etiology of cardiac events associated with MB.     

Pitfalls in the echocardiographic diagnosis of intracardiac and extracardiac masses

Transthoracic and transesophageal two-dimensional (2-D) echocardiography remain the procedures of choice for evaluating cardiac mass lesions. Potential errors in diagnosis can be made, however, if the mass lesion's size, shape, mobility, and attachment to other cardiac structures are not clearly delineated. Usually a left atrial myxoma arises from the interatrial septum at the level of the fossa ovalis. Pitfalls in diagnosis occur when the tumor size is very small, or its attachment site is atypical or ill-defined. Atrial thrombi classically reside in an atrial appendage, but can also form in the body of the left atrium. The presence of atrial fibrillation rhythm, enlarged atrial chamber, prosthetic mitral/tricuspid valves, stenotic mitral/tricuspid valves, low cardiac output state, and spontaneous atrial contrast echoes are all features that favor the mass in question being a thrombus. Ventricular thrombi usually occur with poorly functioning ventricles. The diagnosis of ventricular thrombus should be made with great caution if the systolic function is normal, or if the mass has a band or thread-like appearance. A thorough knowledge of normal anatomical variants that can mimic pathological lesions is also important for reaching a correct diagnosis. Last but not least, as in all testing modalities, the patient's clinical picture should be correlated with the echocardiographic findings.     

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Complex Coronary Artery Disease

ObjectivesThe aim of this study was to compare, in a cohort of patients with complex coronary artery disease (CAD) and severe aortic stenosis (AS), the clinical outcomes associated with transfemoral transcatheter aortic valve replacement (TAVR) (plus percutaneous coronary intervention [PCI]) versus surgical aortic valve replacement (SAVR) (plus coronary artery bypass grafting [CABG]).BackgroundPatients with complex CAD were excluded from the main randomized trials comparing TAVR with SAVR, and no data exist comparing TAVR + PCI vs SAVR + CABG in such patients.MethodsA multicenter study was conducted including consecutive patients with severe AS and complex CAD (SYNTAX [Synergy Between PCI with Taxus and Cardiac Surgery] score >22 or unprotected left main disease). A 1:1 propensity-matched analysis was performed to account for unbalanced covariates. The rates of major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, nonprocedural myocardial infarction, need for new coronary revascularization, and stroke, were evaluated.ResultsA total of 800 patients (598 undergoing SAVR + CABG and 202 undergoing transfemoral TAVR + PCI) were included, and after propensity matching, a total of 156 pairs of patients were generated. After a median follow-up period of 3 years (interquartile range: 1-6 years), there were no significant differences between groups for MACCE (HR for transfemoral TAVR vs SAVR: 1.33; 95% CI: 0.89-1.98), all-cause mortality (HR: 1.25; 95% CI: 0.81-1.94), myocardial infarction (HR: 1.16; 95% CI: 0.41-3.27), and stroke (HR: 0.42; 95% CI: 0.13-1.32), but there was a higher rate of new coronary revascularization in the TAVR + PCI group (HR: 5.38; 95% CI: 1.73-16.7).ConclusionsIn patients with severe AS and complex CAD, TAVR + PCI and SAVR + CABG were associated with similar rates of MACCE after a median follow-up period of 3 years, but TAVR + PCI recipients exhibited a higher risk for repeat coronary revascularization. Future trials are warranted.     

心脏交感神经重构与心律失常:新兴领域的当前认识

心脏内交感神经纤维分布十分广泛,近年发现许多心脏疾病伴有交感神经分布、密度改变的现象,并与心律失常发生、疾病预后都有密切的关联。交感神经重构与心肌组织重构、电重构相互影响,可能是心律失常发生的基础。对交感神经重构进行干预可能成为将来新的一个治疗方向。     

Ionic currents and action potentials in rabbit,rat, and guinea pig ventricular myocytes

Summary Distinct differences exist in action potentials and ionic currents between rabbit, rat, and guinea pig ventricular myocytes. Data obtained at room temperature indicate that about half of the rabbit myocytes show prominent phase 1 repolarization and transient outward current. Action potentials in guinea pig ventricular myocytes resemble those from rabbit myocytes not exhibiting phase 1 repolarization; and guinea pig myocytes do not develop transient outward current. Rat ventricular action potentials are significantly shorter than those from rabbit and guinea pig ventricular myocytes. Unlike rabbit and guinea pig myocytes, rat ventricular myocytes also exhibit a prominent phase 1 and lack a well defined plateau phase during repolarization. All rat ventricular myocytes exhibit a transient outward current which can be best fitted by a double exponential relation. There are no significant differences between the amplitude, voltage dependence and inactivation kinetics of the inward calcium currents observed in rabbit, rat and guinea pig. The steady-state current-voltage relations between –120 mV and –20 mV, which mostly represent the inward rectifier potassium current are similar in rabbit and guinea pig. The amplitude of this current is significantly less in rat ventricular myocytes. The outward currents activated upon depolarization to between –10 and +50 mV are different in the three species. Only a negligible, or absent, delayed rectifier outward current has been observed in rabbit and rat; however, a relatively large delayed rectifier current has been found in guinea pig. These large interspecies variations in outward membrane currents help explain the differences in action potential configurations observed in rabbit, rat, and guinea pig.     

Is there any relationship between adverse pregnancy outcome and first trimester nuchal translucency measurements in normal karyotype fetuses?

Aim: This study aims to research whether there is a relationship between first trimester nuchal translucency (NT) measurements and pregnancy complications such as gestational diabetes mellitus (GDM), gestational hypertension (GHT), intrauterine growth restriction (IUGR) and oligohydramnios.

Method: This study included 225 singleton pregnancies attending Canakkale Onsekiz Mart University Obstetrics and Gynecology clinic for all monitoring and examinations, and gave birth at our clinic between January 2011 and December 2012. Data sources were clinical records and the hospital's automation system, and the study was planned as retrospective cohort. NT measurement was made between 10 weeks 3 days and 13 weeks 6 days gestation. For data analysis, the chi-square, Mann–Whitney U test and Spearman correlation were used.

Results: Of pregnancies, in the study, 5 (2.2%) developed GDM, 6 (2.6%) developed GHT, 2 (0.89%) developed IUGR and 10 (4.4%) developed oligohydramnios. There was no correlation identified between NT measurements and development of GDM, GHT, IUGR and oligohydramnios.

Conclusion: There was no relationship found between first trimester NT measurements and complications that could develop in pregnancy. For the first time in the literature, NT and oligohydramnios were studied and no relationship was observed.     

The atrial appendage as a suitable source to generate cardiac‐derived adherent proliferating cells for regenerative cell‐based therapies

Cardiac‐derived adherent proliferating (CardAP) cells obtained from endomyocardial biopsies (EMBs) with known anti‐fibrotic and pro‐angiogenic properties are good candidates for the autologous therapy of end‐stage cardiac diseases such as dilated cardiomyopathy. However, due to the limited number of CardAP cells that can be obtained from EMBs, our aim is to isolate cells with similar properties from other regions of the heart with comparable tissue architecture. Here, we introduce the atrial appendage as a candidate region. Atrial appendage‐derived cells were sorted with CD90 microbeads to obtain a CD90^low cell population, which were subsequently analysed for their surface marker and gene expression profiles via flow cytometry and micro array analysis. Enzyme‐linked immunosorbent assays for vascular endothelial growth factor and interleukin‐8 as well as tube formation assays were performed to investigate pro‐angiogenic properties. Furthermore, growth kinetic assays were performed to estimate the cell numbers needed for cell‐based products. Microarray analysis revealed the expression of numerous pro‐angiogenic genes and strong similarities to CardAP cells with which they also share expression levels of defined surface antigens, that is, CD29⁺, CD44⁺, CD45^?, CD73⁺, CD90^low, CD105⁺, and CD166⁺. High secretion levels of vascular endothelial growth factor and interleukin‐8 as well as improved properties of vascular structures in vitro could be detected. Based on growth parameters, cell dosages for the treatment of more than 250 patients are possible using one appendage. These results lead to the conclusion that isolating cells with regenerative characteristics from atrial appendages is feasible and permits further investigations towards allogenic cell‐based therapies.     

Gains of Continuing Resuscitation in Refractory Out-of-hospital Cardiac Arrest: A Model-based Analysis to Identify Deaths Due to Intra-arrest Prognostication

Objective: Prognostication bias, in which a clinician predicts a negative outcome and terminates resuscitation (TR) thereby ensuring a poor outcome, is a rarely identified limitation of out-of-hospital cardiac arrest (OHCA) research. We sought to estimate the number of deaths due to intra-arrest prognostication in a cohort of OHCA's, and use this data to estimate the incremental benefit of continuing resuscitation. Methods: This study examined a cohort of consecutive non-traumatic EMS-treated OHCAs from a provincial ambulance service, between 2007 and 2011 inclusive. We used Cox and logistic regression modeling, adjusting for Utstein covariates, to estimate the probability of ROSC, survival, and favorable neurological outcomes as a function of resuscitation time, and applied these models to estimate the number of missed survivors in those who had TR (prior to 20, 30, or 40 minutes). We determined the time juncture at which (1) the likelihood of survival fell below 1%, and (2) the proportion of survivors who had achieved ROSC exceeded 99%. Results: Of 5674 adult EMS-treated cases, 46% achieved ROSC, and 12% survived. The median time of TR was 27.0 minutes (IQR 19.0–35.0). Continuing resuscitation until 40 minutes yielded an estimated 17 additional survivors (95% CI 13–21), 10 (95% CI 7–13) with favorable neurological outcomes. The probability of survival of those in refractory arrest decreased below 1% at 28 minutes (95% CI 24–30 minutes). At 36 minutes (95% CI 34–38 minutes) >99% of survivors had achieved ROSC. Conclusion: We identified possible deaths due to intra-arrest prognostication. Resuscitation should be continued for a minimum of 30 minutes in all patients, however for those with initial shockable rhythms 40 minutes appears to be warranted. Interventional trials and observational studies should standardize or adjust for duration of resuscitation prior to TR.