Acta Cardiologica

Atherothrombosis: a vanishing disease?

poj@peeters-leuven.be — Thu, 19 Nov 2009 11:41:11 GMT

Editorial

A long-term comparison of drug-eluting versus bare metal stents for the percutaneous treatment of coronary bifurcation lesions

poj@peeters-leuven.be — Thu, 19 Nov 2009 11:48:20 GMT

Background � After the first exciting results on drug-eluting stents (DES), many concerns have been raised on their potential risk for late stent thrombosis. Whereas DES appear beneficial at early and mid-term for coronary bifurcation lesions, no data are available on their long-term safety in this setting in comparison to bare metal stents (BMS). We thus aimed to appraise the long-term (> 2 years) outcomes of patients with bifurcation lesions treated with DES vs. BMS. Methods � We abstracted baseline, procedural and follow-up data on all patients with bifurcation coronary lesions (both branches with reference vessel diameter > 2.0 mm) treated with stent implantation at our centre. The primary end-point was the long-term (> 2 years) rate of major adverse cardiac events (MACE, i.e. cardiac death, myocardial infarction, coronary artery bypass grafting and target vessel revascularization). Results � A total of 315 patients and 334 lesions were included, 84.4% treated with DES, and 15.6% treated with BMS. The side branch was stented in 108 cases, according to a provisional T in 76 (22.7%), crushing in 15 (4.5%), V in 14 (4.2%), and culottes in 1 (0.3%). In-hospital MACE occurred in 4 (1.5%) patients of the DES group and 2 (4.1%) of the BMS group (P = 0.22). After 35.8 � 12.9 months, MACE were 72 (27.1%) vs. 24 (49%), respectively (P = 0.002), with cardiac death in 7 (2.6%) patients vs. 3 (6.1%, P = 0.20), myocardial infarction in 12 (4.5%) vs. 6 (12.2%, P = 0.42), coronary artery bypass grafting in 5 (1.9%) vs. 1 (2%, P = 0.93), target lesion revascularization in 30 (11.3%) vs. 13 (26.5%, P = 0.0042), and target vessel revascularization in 48 (18%) vs. 13 (26.5%, P = 0.16). Definite stent thrombosis occurred in 2 (0.75%) patients in the DES group vs. 1 (2%, P = 0.93) in the BMS group, whereas probable stent thrombosis was adjudicated in 5 (1.9%) vs. 2 (4%, P = 0.93). Conclusion � This cohort study, reporting for the first time on the long-term outlook of patients treated with DES vs. BMS for coronary bifurcation lesions, supports the overall safety and efficacy of DES in comparison to BMS. Specifically, even after several years of follow-up, repeat revascularizations appeared significantly lower with DES, and stent thromboses occurred with equivalent frequency in both DES and BMS groups.

Decrease in plasma brain natriuretic peptide level in the early phase after the start of carvedilol therapy is a novel predictor of long-term outcome in patients with chronic heart failure

poj@peeters-leuven.be — Thu, 19 Nov 2009 11:56:05 GMT

Objective � The purpose of the present study was to determine whether change in plasma brain natriuretic peptide (BNP) level at an early phase of carvedilol therapy is a predictor of improvement in cardiac function and long-term prognosis in patients with systolic chronic heart failure (CHF). Methods and results � Neurohumoral factors and haemodynamics were examined in 64 patients with systolic CHF (left ventricular ejection fraction (LVEF) below 45%) before and one month (early phase) and 3 to 6 months (late phase) after the start of carvedilol therapy. These patients were followed up for a mean period of 57 months. Plasma BNP levels were already decreased in the early phase before improvement of LVEF in response to carvedilol therapy. Univariate and multivariate linear regression analyses showed that Δ log brain natriuretic peptide (BNP)_E (= log BNP at baseline � log BNP at early phase) (P < 0.0001) was a significant independent predictor of improvement in LVEF in the late phase. Cardiac events occurred in 11 patients during the follow-up period. In addition, multivariate Cox proportional hazards regression analysis showed that Δ log BNP_E (P = 0.0045) and systolic blood pressure at baseline (P = -0.048) were significant independent predictors of the development of cardiac events. Conclusions � Decrease in plasma BNP level in the early phase of carvedilol therapy is a novel predictor of not only improvement of LVEF in the late phase but also prognosis in patients with systolic CHF.

Impaired aortic elasticity in patients with psoriasis

poj@peeters-leuven.be — Thu, 19 Nov 2009 13:46:18 GMT

Background � Psoriasis vulgaris is a chronic inflammatory disease involving 1-3% of the human population worldwide. Many systemic diseases including cardiovascular disturbances have been described in psoriatic patients. The effect of psoriasis on aortic elasticity parameters has not been well-defined previously. The aim of this study was to determine whether there was any change in aortic elasticity in psoriasis. Methods � Twenty-seven psoriatic patients without cardiovascular involvement and 22 healthy subjects were enrolled into the study. The severity of the disease was evaluated by the 'Psoriasis Area and Severity Index (PASI)'. Aortic strain, distensibility and stiffness index were calculated from aortic diameters measured by echocardiography and blood pressures simultaneously measured by sphygmomanometry. Results � The aortic strain and distensibility in the psoriasis group were significantly lower than those in the control group. The aortic stiffness index in the psoriasis group was higher than that in the control group. There was a positive correlation between aortic stiffness index and PASI and longevity of psoriasis disease, whereas a negative correlation between aortic strain and PASI and longevity of psoriasis disease was found. Conclusion � We found that in psoriatic patients without cardiac involvement, aortic elasticity was decreased and this decrease was correlated with the duration and the severity of the disease.

Levels of proinflammatory cytokines and hs-CRP in patients with homozygous familial hypercholesterolaemia

poj@peeters-leuven.be — Thu, 19 Nov 2009 13:52:03 GMT

Objective � Homozygous familial hypercholesterolemia (FH) is an extremely rare (1/1.000.000) condition characterized by markedly increased LDL cholesterol levels and a significantly increased risk of premature coronary heart disease (CHD). We aimed to evaluate the levels of high-sensitivity C-reactive protein (hs-CRP) and proinflammatory cytokines, which are known to be associated with atherogenesis, in patients with this condition. Method and results � A total of 10 patients with homozygous FH (5 women and 5 men, mean age 17.0 � 6.9 years, body mass index (BMI) (18.8 � 1.9 kg/m²) and 16 healthy controls were included. hs-CRP levels, proinflammatory cytokine levels and lipid parameters were measured and compared between patients and control subjects. Homozygous FH patients had significantly higher total cholesterol, LDL-cholesterol and Lp(a) levels and significantly lower triglyceride and HDL cholesterol levels, compared to controls (P = 0.0001, for all). Serum hs-CRP (3.7 � 1.3 mg/L vs. 0.6 � 0.6 mg/L) and IL-1β, IL-2R, IL-6, IL-8, IL-10, TNF-α levels were all significantly higher in the homozygous FH group, compared to controls (P = 0.0001, for all). Conclusions � Homozygous FH patients have significantly higher levels of hs-CRP and circulating proinflammatory cytokines, which may explain their increased risk of atherosclerotic disease. hs-CRP is an important biomarker that may be helpful in the identification of asymptomatic CHD in FH patients.

Post-intervention IVUS is not predictive for very late in-stent thrombosis in drug-eluting stents

poj@peeters-leuven.be — Thu, 19 Nov 2009 13:55:01 GMT

Objectives � Stent thrombosis is a life-threatening complication associated with sudden death and acute myocardial infarction. Histopathologic studies have linked the occurrence of very late stent thrombosis in drug-eluting stents (DES) with delayed endothealisation and stent malapposition. Our aim was to investigate if late stent malapposition in DES could be predicted by immediate postintervention intra-vascular ultrasonography (IVUS). Methods and results � From our MISSION! database of 184 consecutive patients with ST-elevation myocardial infarction (STEMI) who had immediate post-intervention and nine-month follow-up IVUS examinations we prospectively identified three patients with very late (> 365 days) and definite (with angiographic evidence) in-stent thrombosis in DES. Patients had completed the twelve-month clopidogrel-aspirin dual treatment period, two of them were under aspirin therapy while the third patient had aspirin temporarily discontinued before planned surgery. When assessed by serial documentary (immediate post-intervention and nine-month) IVUS, all three patients demonstrated stent malapposition at nine months: in two cases the malapposition was acquired (immediate post-intervention IVUS showed a well apposed stent) and one case presented persistent malapposition (the stent was found malapposed both at immediate post-intervention and nine-month follow-up IVUS). Conclusions � Immediate post-intervention IVUS showing no malapposition does not guarantee an uneventful course after DES implantation.

Masked diastolic dysfunction caused by exercise testing in hypertensive heart failure patients with normal ejection fraction and normal or mildly increased LV mass

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:06:31 GMT

Introduction � It is not clear whether in patients with the clinical suspicion of heart failure with normal ejection fraction (HFNEF) exercise assessment of diastolic function may help to unmask abnormalities not detected by resting measurements. Methods and results � A combined radionuclide angiographic and haemodynamic exercise study was performed to confirm definite diastolic dysfunction in hypertensive patients with exertional dyspnoea and no other detectable cause of their symptoms. Only patients with normal baseline left ventricular (LV) systolic and diastolic function parameters as evaluated by routine cardiac catheterization and transmitral Doppler echocardiography were accepted (n = 38). All parameters were compared to a control group (n = 10). Twenty-eight patients showed an abnormal elevation in pulmonary capillary wedge pressure with exercise. As a consequence of a reduced exercise stroke volume (58 � 13 vs. 70 � 12 ml/m²; P = 0.01) peak cardiac output was reduced in HFNEF (9.3 � 1.7 vs. 7.6 � 2.0 l/min/m²; P = 0.02). These changes were equally demonstrable in patients with and without ventricular hypertrophy. LV end-systolic wall stress (ESWS) was increased at rest and during exercise in HFNEF patients without hypertrophy. However, a positive relationship between ESWS and the corresponding exercise stroke volume (r = 0.57; P = 0.002) was observed in the entire HFNEF group. Conclusion � Detection of diastolic dysfunction in suspected HFNEF is not only a question of the diagnostic methods used, but of the conditions under which the patients are investigated.

Angiographic characteristics of major intramural coronary arteries and their effect on coronary bypass surgery

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:11:11 GMT

Objective � Dissection of intramyocardial coronary arteries can cause technical problems in coronary bypass surgery, including bleeding and inadvertent ventricular perforation, which can prolong the operation time. The goal of this study was to assess the effects of intramural coronary arteries on coronary bypass surgery and to define the angiographic characteristics of these coronary arteries. Methods and results � We studied 112 patients (60.12 � 10.23 y, 98 M) who underwent coronary bypass surgery, half of whom had intramural coronary arteries. Coronary angiographies were revised just after surgery, and characteristics of intramural coronary arteries were documented by combining surgical findings and angiographies. In angiographic examinations, studied intramural segments of the coronary arteries had less angulations in contrast to matched segments of control groups (mean 1.1 � 0.3 vs. 2.46 � 1.04, P < 0.001), and the angles were significantly smaller (13.25 � 11.28 degrees vs. 24.11 � 11.0 degrees P < 0.001). During surgery the intramural portions of the coronary arteries appeared to be free of atherosclerotic plaques. Mean cross clamp time of patients with intramural coronary arteries was longer than that in control patients (58.86 � 19.65 vs. 48.29 � 16 68, P < 0.01). Conclusions � Major intramural coronary arteries can be diagnosed preoperatively by angiographic examination. Overlying myocardial bands play a protective role against coronary artery atherosclerosis.

Does time delay between the primary cardiac arrest and PCI affect outcome?

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:16:15 GMT

Objectives � In patients with acute ST-segment elevation acute myocardial infarction (AMI), no data are available on the prognostic value of cardiac arrest (CA) due to ventricular fibrillation (VF) before, during, and after percutaneous coronary intervention (PCI). The aim of our study was to determine differences in prognosis between patients with CA before, during, and after PCI. Methods � Among 448 patients with first ST-segment elevation AMI, we selected 34 (7.6%) with primary CA due to VF and 6 (1.3%) with secondary CA. The patients with primary CA were categorized into groups according to the time of the first episode of the primary CA, either before [12 (35.3%)], during [18 (52.9%)], or after [4 (11.8%)] PCI procedure. The 30-day all-cause mortality rate was analysed. Results � Short-term mortality was: (i) in patients without CA: 7.1% (29/408); (ii) in patients with primary CA 35.3% (12/34); (iii) in patients with secondary CA 50% (3/6); (P < 0.001). Mortality was 8.3% (1/12) in patients with primary CA before PCI; 44.4% (8/18) in patients with primary CA during PCI; 75% (3/4) in patients with primary CA after PCI procedure; (P = 0.007). Conclusions � Patients with a primary CA have the same poor prognosis as patients with a secondary CA. The prognosis worsened according to the time of the occurrence of the primary CA. It might be reasonable to isolate subgroups of ST-segment elevation AMI patients treated with PCI with primary CA according to time of primary CA.This could help to better stratify the risk of these patients.

Reduction of cardiovascular event rate: different effects of cardiac rehabilitation in CABG and PCI patients

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:22:20 GMT

Objective � In coronary artery disease, the implementation of a cardiac rehabilitation (CR) programme favourably affects cardiovascular prognosis. However, it remains uncertain whether patients benefit to a similar extent from CR after coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). In this study, we have assessed whether CR is equally effective for suppressing the two-year cardiovascular event incidence after CABG or PCI. Methods and results � 194 PCI and 149 CABG patients participated in a three-month CR programme, while 245 PCI and 89 CABG patients received standard care. After the completion of CR during a two-year follow-up, data on cardiovascular risk factors, medication and cardiovascular events (repeat coronary revascularisation, acute myocardial infarction, and death) were collected from hospital files. Both CABG and PCI patients included into CR showed a significantly lower mortality, as compared to control patients (0.6% vs. 4.2%, P < 0.05). However, total cardiovascular disease incidence was significantly lower as a result of CR in CABG patients (4.7% vs. 14.0%, P < 0.05), but not in PCI patients (19.1% vs. 22.4%, P > 0.05). Conclusion � When following a similar 3-month cardiac rehabilitation programme, the reduction of cardiovascular disease incidence during 2 years of follow-up is different between PCI and CABG patients.

Aortic root dilatation is associated with carotid intima-media thickness but not with carotid plaque in hypertensive men

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:26:29 GMT

Background � The role of atherosclerosis-related processes in aortic root dilatation (ARD) has not been fully determined. The present study was to assess the relationship between carotid IMT, carotid plaque, and ARD. Methods � Hypertensive men with ARD (n = 30) were compared with hypertensive men without ARD (n = 52) and normal control subjects (n = 29). Two-dimensional echocardiography was used to measure the aortic root at the aortic annulus, the sinus of Valsalva, the sinotubular junction and the proximal part of the ascending aorta. Carotid IMT and carotid plaque were also assessed by ultrasound. Results � The measured mean carotid IMT was significantly increased in patients with ARD (1.37 � 0.80 mm) compared to the subjects without ARD (1.06 � 0.54 mm) and healthy control subjects (0.84 � 0.44 mm) (P < 0.05). However, no significant differences of the prevalence of carotid plaque were found in the three groups (P > 0.05). Aortic diameters at all levels except for the diameter of the supra-aortic ridge were significantly related to carotid IMT when the hypertensive population was considered (P < 0.05). No significant correlation was found between carotid plaque and aortic root dimension (P > 0.05). Conclusion � This study shows that carotid intima-media thickening, but not carotid atherosclerotic plaque, is positively associated with ARD. Further studies to explore the underlying mechanism are awaited.

Chronic aortic dissection: still a challenge

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:28:11 GMT

Chronic aortic dissections are complex lesions with a fairly predictable natural history depending on factors such as baseline aortic diameter, the degree of false lumen thrombosis, the presence of a persistent communication, an underlying connective tissue disorder, and the control of hypertension. Medical management with antihypertensive therapy including beta-blockers is the treatment of choice for all stable chronic aortic dissections. Repair is indicated in the case of complications: aortic rupture, malperfusion syndromes, symptomatic dissections, asymptomatic dissections becoming significantly aneurysmal or demonstrating a rapid growth rate. In this regard, serial imaging of the aorta is crucial to detect unstable lesions requiring surgery or an endovascular intervention. As endograft technologies improve endovascular approach may become the future standard of care.

Novel use of a subcutaneous shock lead to create an epicardial implantable cardioverter/ defibrillator system via a limited thoracotomy

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:30:31 GMT

We report the case of a novel use of a subcutaneous shock lead to create an epicardial implantable cardioverter/defibrillator (ICD) system via a limited thoracotomy in a patient with poor vascular access. Performance of the system is comparable to the conventional ICD system without the disadvantages of other available epicardial ICD systems.

Angina pectoris as first manifestation of a huge biatrial myxoma

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:33:29 GMT

A 73-year-old woman with a history of atrial fibrillation suffered from exertional chest pain and discrete dyspnoea. Cardiac catherization showed a vascular malformation in the atria, fed from vessels of the circumflex and left descending coronary artery. Echocardiography detected a biatrial tumour (13.7 x 9.7 cm). The tumour mass was completely removed and histologic examination revealed a biatrial myxoma with extensive vascular lesions which apparently induced angina by coronary steal effect.

Pericarditis with massive pericardial effusion in a cytomegalovirus-infected infant

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:34:50 GMT

We report a case of pericarditis with massive pericardial effusion in a female infant with cytomegalovirus (CMV) infection. Viral infection is a common cause of acute myocardial and pericardial disease; most of these patients are infected with enterovirus and are asymptomatic. Cardiac involvement in CMV infection is rare, with CMV-related pericarditis being reported mainly in patients who were immunocompromised as a result of autoimmune deficiency syndrome (AIDS) or organ transplantation. This paper describes a 3.5-month-old breastfed infant girl with a healthy history, who presented with CMV infection.

Heart failure in a patient with corrected transposition of the great arteries. When is biventricular pacing indicated?

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:37:43 GMT

This report presents a patient with complex congenitally corrected transposition of the great arteries (ccTGA) and concomitant ventricular septal defect (VSD), who developed symptomatic heart failure further aggravated after dual-chamber pacemaker implantation. The initial disqualification from surgery based on high vascular pulmonary resistance was verified in repeated catheterization. The oxygen test was positive, therefore the patient underwent surgical correction. Despite successful repair with the use of two prosthetic valves (mechanical and biological) and an intraventricular patch, the symptoms of heart failure persisted. In view of the prolonged QRS complex on the ECG and the signs of significant intraventricular mechanical dyssynchrony measured by Tissue Doppler Imaging (TDI), the patient was referred for cardiac resynchronization therapy (CRT). A biventricular pacemaker allowed a larger synchronicity of systemic RV systolic function and the improvement of the patient�s general condition. The case described indicates that optimal care in patients with ccTGA can require implementation of both surgical and electrophysiological methods of treatment.

Intimal sarcoma of the pulmonary artery: a report of two cases

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:39:16 GMT

Intimal sarcoma of the pulmonary artery (PAS) is a rare but potentially lethal tumour, frequently misdiagnosed as chronic thrombo-embolic pulmonary artery disease. Despite the availability of advanced imaging technologies, its preoperative diagnosis remains difficult. We report on two patients with clinical features mimicking chronic pulmonary thrombo-embolism. Further discussion will focus on the differential diagnosis with more classical causes of obstructive pulmonary vascular disease.

Electrical storm in a patient with dilated non-ischaemic cardiomyopathy

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:40:31 GMT

Bundle-branch re-entrant ventricular tachycardia (BBRVT) is usually seen in patients with dilated cardiomyopathy. The diagnosis should be suspected in case the QRS morphology during the tachycardia is identical to that in sinus rhythm. Identifying patients with BBRVT is important because they can be easily treated by catheter ablation. This report describes a patient previously implanted with a cardiac resynchronization therapy defibrillator (CRT-D) presenting with an electrical storm due to BBRVT.

Cryptogenic stroke in the presence of venous bronchopulmonary collateralisation

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:41:57 GMT

We report the case of a 37-year-old man with a history of Hodgkin lymphoma and paroxysmal atrial fibrillation, seen because of a transient ischaemic attack with symptoms of temporary aphasia. Transoesophageal echocardiography could not detect a patent foramen ovale. However, CT thorax and flebography showed bilateral occlusion of both subclavian veins and the superior vena cava with an important collateral venous network, most likely responsible for this rare case of acquired cryptogenic stroke.

Spontaneous jugular vein thrombosis

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:43:54 GMT

Jugular vein thrombosis (JVT) is usually secondary to central venous catheterisation, distant malignancy, hypercoagulable state or ovarian hyperstimulation syndrome. Spontaneous internal JVT is an extremely rare entity. A 61-year-old man presented with swelling of the right side of his face. An ultrasonographic scan showed thrombosis of the right jugular vein. Clinical tests, including oncomarkers, X-ray, CT scan and abdominal ultrasonography, searching for malignancy, were negative. The patient was heparinized immediately using LMWH and then underwent warfarin anticoagulation therapy for 6 months. One year later the patient was in good clinical condition with no malignancy diagnosed. Aetiology and the treatment of spontaneous JVT are discussed.

Noninvasive evaluation of a coronary-pulmonary artery fistula

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:45:08 GMT

Coronary angiography can be used to identify the size and anatomical features of coronary artery fistulas (CAF), but it may fail to depict the drainage site of the CAF or its relation to other structures. In our case, the combined use of CT and CMR provided all the necessary information for clinical management.

Twiddling with an implantable cardioverter-defibrillator

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:46:32 GMT

A 64-year-old woman underwent implantation of a single-chamber implantable cardioverter-defibrillator. The active fixation lead was positioned in the right ventricular apex and the generator in a left pre-pectoral pocket. Device interrogation 4 weeks after implantation revealed inappropriate sensing and failure of pacing. A chest X-ray showed the entire lead coiled behind the device. The patient admitted manipulating the device and a diagnosis of Twiddler�s syndrome was made. After repositioning the lead, the generator was re-located in the sub-pectoral position to help prevent recurrence by reducing the ability to externally manipulate the device.

Belgian Society of Cardiology. Belgian Heart Rhythm Association (BeHRA)

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:47:15 GMT

not available

Erratum

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:49:02 GMT

Figure 3 of the article published in Acta Cardiol 2008; 63(3) on page 380 should be replaced by the figure published in this Erratum.

Book Reviews

poj@peeters-leuven.be — Thu, 19 Nov 2009 14:49:52 GMT

Book reviews