Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over th... more Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over the past decade acute myocardial infarction treatment has changed because of new thrombolytic therapies and consequently, the value of exercise testing is under debate. The GISSI-2 database allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 patients, on average 28 days after randomisation. The test was not performed in 3923 patients because of contraindications. The test was judged positive for residual ischaemia in 26% of the patients, negative in 38%, and non-diagnostic in 36%. Among the patients with a positive stress test result, 33% had symptoms, whereas 67% had silent myocardial ischaemia. The mortality rate was 7.1% among patients who did not have an exercise test and 1.7% [correction of 7.1%] for those with a positive test, 0.9% for those who had a negative test, and 1.3% for those who did not have a diagnostic test. In the adjusted analysis, symptomatic induced ischaemia, submaximal positive result, low work capacity, and abnormal systolic blood pressure were independent predictors of 6-month mortality (relative risks [RR] 2.54, 95% CI 1.27-5.08, 2.28, 1.17-4.45, 2.05, 1.23-3.42, and 1.86, 1.05-3.31, respectively). However, when these factors were tested simultaneously, only symptomatic induced ischaemia and low work capacity were confirmed as independent predictors of mortality (RR Cox 2.07, 95% CI 1.02-4.23 and 1.78, 1.06-2.99, respectively). Patients with a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation should be devoted to the patients who cannot undergo exercise testing, because the potential to influence outcome appears to be much greater.
Tissue-type plasminogen activator (t-PA) is a serine protease that converts a zymogen plasminogen... more Tissue-type plasminogen activator (t-PA) is a serine protease that converts a zymogen plasminogen into an active serine protease, namely, plasmin. Plasmin is the proteolytic enzyme that degrades fibrin. In the absence of fibrin, e.g., in circulating plasma, t-PA activates plasminogen at a very slow rate. However, when fibrin is present, this activity is enhanced two to three orders of magnitude. As a consequence of these kinetic characteristics, plasmin is predominantly generated on the fibrin surface. This in turn results in a relative sparing of circulating fibrinogen and other plasma proteins to plasmin--mediated degradation. Following the demonstration of the potential of natural t-PA as a thrombolytic agent, an intensive effort was launched to enhance its production by recombinant DNA technology. The pharmacological action and the clinical efficacy of t-PA has been tested by several Authors in the treatment of acute myocardial infarction (AMI), and more recently, of pulmonary e...
A case of Staphylococcus aureus tricuspid valve endocarditis in a patient with permanent transven... more A case of Staphylococcus aureus tricuspid valve endocarditis in a patient with permanent transvenous VVI pacemaker and recurrent febrile episodes is described. Medical treatment was not effective, and only with surgical removal of the lead was the infection successfully treated.
Congestive heart failure is recognized as a major public health issue and is the leading cause of... more Congestive heart failure is recognized as a major public health issue and is the leading cause of death in western countries. Heart transplantation currently remains the gold standard option for end-stage heart failure patients. Heart transplantation is also one of the most limited therapies, not only with regard to the lack of donor hearts but also because of the surgical limitations inherent to the clinical aspects of this severely ill patient population. Mechanical circulatory support systems have been developed as effective adjuvant therapeutic options in these terminally ill patients. Over the past two decades, mechanical circulatory support devices have steadily evolved in the clinical management of end-stage heart failure, and have emerged as a standard of care for the treatment of acute and chronic heart failure refractory to conventional medical therapy. Future blood pumps should be smaller and totally implantable, as well as more efficient, biocompatible, and reliable.
European Journal of Heart Failure Supplements, 2003
Background: CRT improves functional status and may be prognosis in HF pts with interventricular c... more Background: CRT improves functional status and may be prognosis in HF pts with interventricular conduction delay. Ischemic etiology is known to portend a worse prognosis in the overall population of heart failure pts. Objective: To compare functional and clinical outcome after CRT in pts with HF of ischemic vs non-ischemic etiology. Methods: Clinical improvement (decrease of at least 1 NYHA functional class), mortality and change in functional parameters were analyzed in 106 patients (males 86%, mean age 61±9 years, NYHA class 3.0±0.5) who underwent CRT. The outcome was compared in pts with ischemic (n=38, 36%) and nonischemic (n=68, 64%) etiology, after a mean followup of 15±10 months. Regarding demographics and baseline clinical variables, nonischemic group had a higher prevalence of females (20.6% vs 2.6%; p<0.01) and greater left ventricular end-diastolic volume-LVEDV (p<0.05) than ischemic group. Mean age was higher in ischemic pts (65±9 vs 59±10 y., p<0.005). Results: Clinical improvement was more frequent (63/68, 93%) in pts with nonischemic than in pts with ischemic etiology (26/38, 68%, p<0.005). There were 3 deaths in nonischemic (4.4%) and 6 in ischemic pts (15.8%, p: n.s.). Both groups showed a significant increase of peak exercise VO2 (non isch from 12.2±3.8 to 14.3±3.7 ml/Kg/min, p<0.01; isch from 13.3±1.5 to 14.3±3.6 ml/Kg/min, p=0.03) and a significant decrease of LVEDV (non isch from 284±110 to 241±97 ml, p<0.001; isch from 233±66 to 216±64 ml, p=0.02) and of mitral regurgitation score (non isch from 2.1±1.1 to 1.7±0.9, p<0.01; isch from 1.9±0.9 to 1.5±0.7, p=0.02). Only nonischemic pts showed a significant increase of mean LV ejection fraction-LVEF (non isch from 25±7% to 31±8%, p<0.001; isch from 28±9% to 29±8%, p:n.s.). The subgroup of pts with ischemic etiology that experienced clinical improvement had a slight but not significant increase of LVEF (from 27±7 to 30±8; p=0.07). Inferences: After CRT, clinical and functional improvement occurs in the majority of pts with HF of any etiology, but less frequently in those with ischemic heart disease. Taking into account the regional structural and functional abnormalities that characterize this disease, it is possible that careful echo-guided search for the best pacing site at LV lead implantation would increase the rate of success of CRT in pts with HF of ischemic etiology.
European Journal of Heart Failure Supplements, 2003
Background: Symptoms and functional status in patients suffering from heart failure (HF)is often ... more Background: Symptoms and functional status in patients suffering from heart failure (HF)is often evaluated by qualitative and subjective methods. Aim of the study was to measure patient activity on objective and quantitative daily basis and correlate activity trend with standard outcome measurements. Methods: 39 pts (69% male, mean age 71.9±23.9 years old, mean NYHA class 2.9±0.8, mean ejection fraction (EF) 29.2±10.0%, mean QRS width 165.1±29.3 ms, with advanced HF have been implanted with an InSync III (Model 8042, Medtronic Inc.) biventricular stimulator. At each follow up (FU) visit, scheduled at 1, 4, 7 and 10 months after implant, diagnostics device memory and clinical data were collected. InSync III device continuously collects daily information concerning patient activity measuring the amount of time patient is active. In each minute, the number of activity sensor counts is accumulated and if the counts exceed a fixed threshold, the patient is considered active. The threshold is set so that continuous 70 steps per minute walk will be registered as active. Results: At 10 months FU NYHA class(2.0±1.0, P<0.001)and QRS duration(128.4±20.6 ms, P<0.0001)significantly decreased and EF significantly improved (37.2±11.6, P<0.01) in comparison with baseline. Patient activity data showed a significant increase from 52±81 minutes/day at pre-discharge to 235±128 minutes/day at 10 months FU(P<0.001). Mean activity trend is shown in the figure.
The Journal of Heart and Lung Transplantation, 2001
transgenes for human DAF. There are concerns about levels of immunosuppression and the risk of tr... more transgenes for human DAF. There are concerns about levels of immunosuppression and the risk of transmission of PERVs. The benefit of the transplant should not be out weighed by the risk of systemic disease. We report cases of a systemic vasculitis in the non-transplanted organs of xenograft recipients. Materials: Cynomologous monkeys received renal xenografts from pigs transgenic for hDAF. Several immunosuppressive protocols were used but were based on cyclosporin and steroids. Some received induction cyclophosphamide. Animals that died or sacrificed following transplantation had an autopsy with tissues submitted for histology. Results: In 208 transplants with survival Ͼ 1 day, 10 cases had histological evidence of a vasculitis. Median survival in all cases was 7 days against 29 days in the vasculitis cases. Tissue sampling protocols have changed and may under estimate the true frequency. The lesions showed fibrinoid necrosis of small muscular vessels with inflammatory cell debris. Lesions were seen in the submucosal vessels of the GI tract in 9 cases and in the pancreas in 1 case. Lesions were seen in the heart, adrenal and lymph node in 1 case each. 3 cases were associated with CMV infection but no inclusions were seen in relation to the vasculitic lesions. No occlusive thrombi or necrosis was seen.Immunohistochemistry showed &alpha-gal in the fibrinoid areas with detectable immunoglobulins in a number of cases. There was no correlation with severity of rejection.
The Journal of Heart and Lung Transplantation, 2009
Purpose: Functional mitral regurgitation (fMR) is associated with increased morbidity and mortali... more Purpose: Functional mitral regurgitation (fMR) is associated with increased morbidity and mortality in patients with idiopathic dilated cardiomyopathy (DCM). However, indication for mitral annuloplasty is still controversial. We examined the outcomes of restrictive mitral annuloplasty for DCM and the factors related to reverse remodeling. Methods and Materials: Twenty five patients with significant left ventricular (LV) dysfunction (LV end-diastolic dimension; LVEDD Ͼ/ϭ 60 mm, LV ejection fraction; LVEF Ͻ/ϭ 35%) and fMR (grade 3 or 4) due to DCM underwent restrictive mitral annuloplasty with downsizing of the mitral annulus using Phisyo-ring. Myocardial tissue was obtained from LV anterior wall by needle biopsy during the operation and the degree of cardiac fibrosis was measured. Results: During 18 Ϯ 13 months of follow up periods, there was 1 operative death due to multiple organ failure and 2 late deaths due to sepsis. New York Heart Association functional class improved from 3.4 Ϯ 0.6 to 2.0 Ϯ 0.8 (P Ͻ 0.0001). Postoperative echocardiography revealed grade 3 MR in 1 patient and grade 2 in 3. LVEDD decreased from 73.6 Ϯ 9.1 to 70.5 Ϯ 9.6 mm (P ϭ 0.0002) and mean pulmonary artery pressure decreased from 30.9 Ϯ 9.7 to 24.0 Ϯ 8.2 mmHg (P ϭ 0.0088). Cardiac index increased from 2.1 Ϯ 0.8 to 2.5 Ϯ 0.7 L/min/m 2 (P ϭ 0.0440). Histological examination of the LV anterior wall myocardium revealed degree of fibrosis ranged from 8.2% to 47.7% (mean 28.3 Ϯ 12.8%). Although there was no clinical hemodynamic or echocardiographic factor significantly correlates with LV reverse remodeling, the degree of myocardial fibrosis correlated significantly with decrease in LVEDD (P ϭ 0.0369, r ϭ -0.69) and pulmonary artery pressure (P ϭ 0.0478, r ϭ -0.63). Conclusions: Restrictive mitral annuloplasty improved symptoms and hemodynamics in patients with end-stage heart failure due to DCM. The degree of fibrosis of LV myocardium was the significant predictor of reverse remodeling after restrictive mitral annuloplasty.
The Journal of Heart and Lung Transplantation, 2004
Background: Cardiac resynchronization therapy (CRT) produces clinical benefit in heart failure (H... more Background: Cardiac resynchronization therapy (CRT) produces clinical benefit in heart failure (HF) patients (pts) with intraventricular conduction delay. Previous studies excluded pts who already had a pacing device. In this study, pts with denovo (DN) CRT were compared to those undergoing upgrade (UP) to CRT from standard pacing.
The Journal of Heart and Lung Transplantation, 2004
transplantation, and 5 bilateral lung transplantation with repair of the underlying defect. This ... more transplantation, and 5 bilateral lung transplantation with repair of the underlying defect. This represented 4%, 27% and 3 % of all patients undergoing heart, heart-lung and bilateral lung transplantation respectively. Patients undergoing heart transplantation either had complex abnormalities with low pulmonary artery pressure (n ϭ 37) or myocardial failure after previous reparative operations (n ϭ 23). Fourteen patients undergoing heart-lung transplantation had complex pulmonary atresia and 115 had CHD with pulmonary hypertension. The type of operation has been modified during the period under review to take account of the increasing scarcity of donor organs. Operative techniques are adapted according to the complexity of the underlying anatomy. In-hospital mortality was 20/60 (33%) for hearts, 41/115 (36%) in heart-lung transplantation for CHD and pulmonary hypertension and 12/14 (85%) for complex pulmonary atresia. There were no deaths in the five patients undergoing bilateral lung transplantation and repair. Major risk factors for early death in the heart-lung transplant group were complex pulmonary atresia, previous lateral thoracotomy and age greater than 35 years at transplant. Actuarial survival in the heart transplants was 60%, 54% and 46% at 1 year, 5 years, and 10 years respectively and 61%, 45% and 36% at 1 year, 5 years and 10 years respectively for heart-lung transplant patients with CHD and pulmonary hypertension. It is concluded that risk of early death is greater in patients with complex CHD undergoing heart transplantation than in patients with acquired heart disease. Thereafter survival in patients with CHD is similar to other patients undergoing heart or heart-lung transplantation.
The Journal of Heart and Lung Transplantation, 2007
angiography and adenosine nuclear tests that were obtained within 90 days from one another. We de... more angiography and adenosine nuclear tests that were obtained within 90 days from one another. We determined the ability of nuclear stress testing to accurately predict hemodynamically significant coronary lesions, defined as Ն70% angiographic stenosis. Results: The adenosine nuclear stress test was able to detect significant CAV in only 6 of 19 patients with significant coronary lesions. The test thus had a sensitivity of only 31.5%, but a specificity of 50%, a positive predictive value of 75%, and a negative predictive value of 13%. The adenosine nuclear study was also not effective in identifying patients with small vessel disease. Conclusions: Even with pharmacologic stress, nuclear perfusion imaging is a poor substitute for coronary angiography for the detection of CAV. The limitation in heart transplant patients is more likely due to the diffuse nature of the disease. Diffuse three vessel disease may produce balanced ischemia and consequently a false negative study.
In selected patients with postinfarction angina and impending reinfarction, thrombolysis with rec... more In selected patients with postinfarction angina and impending reinfarction, thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) or streptokinase is highly effective in avoiding a new myocardial infarction. To avoid major cardiac events, we treated 14 consecutive patients with thrombolytic therapy because of impending reinfarction with ECG ST-segment elevation. Thirteen patients received rt-PA (100 mg over 3 hours), and one patient received streptokinase (1.5 million IU over 1 hour). All patients had failed to respond to maximal medical therapy with intravenous nitrates, beta-blockers, Ca-antagonists, heparin, and opiates. In all patients, clinical and ECG signs of acute ischemia resolved completely within 1 hour after beginning thrombolysis, and no patient developed biochemical markers of myocardial infarction. Ten patients underwent coronary angiography: five had three-vessel disease, two had two-vessel disease, and three had one-vessel disease. The culprit lesion was located in the left anterior descending artery in eight cases and the right coronary artery in two. No patient showed intracoronary thrombus. Four patients underwent successful, semiurgent percutaneous transluminal coronary angioplasty; three received an elective and two an urgent coronary artery bypass graft. Thrombolysis (or repeated thrombolysis) is effective in selected patients with clinical ECG signs of impending reinfarction. It can temporarily stabilize the condition of many patients, thus allowing safer mechanical revascularization to be performed.
Symptomatic heart failure is preceded by a somewhat prolonged asymptomatic stage in many patients... more Symptomatic heart failure is preceded by a somewhat prolonged asymptomatic stage in many patients. The number of patients with asymptomatic heart dysfunction is about 4-fold greater than the number of patients with clinically overt heart failure. Pharmacologic treatment with angiotensin-converting enzyme inhibitors and -blockers (in particular carvedilol) of asymptomatic patients with systolic left ventricular (LV) dysfunction can prevent or delay the occurrence of symptoms and reduce mortality in the long term. Thus, it would be of utmost importance to recognize and appropriately treat these patients before they develop heart failure symptoms. The cost-effectiveness of screening for asymptomatic heart dysfunction in the general population and in cohorts at risk has not been extensively evaluated. A normal electrocardiogram has a high negative predictive value in patients at risk. Echocardiography is the best tool for diagnosis and characterization of heart dysfunction, but extensive use is limited by availability and cost. Natriuretic peptides (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) are very sensitive markers of heart dysfunction and volume overload, and their measurement has been proposed as a first-line test to select patients who need echocardiography. The definition of the etiology of LV dysfunction-in particular, of the ischemic etiology-has prognostic and therapeutic implications. In addition to revascularization, pharmacologic treatment with antiplatelets and statins is helpful in preventing new ischemic events and the development of heart failure. The prevention, or at least the delay, of clinical manifestations of heart failure is strongly related to an effective approach to the asymptomatic stage. Therefore, it is important to educate the entire medical community, particularly physicians in the primary care setting, about recognition and treatment of these patients. ᮊ2003 by Excerpta Medica, Inc. Am J Cardiol 2003;91(suppl):4F-9F
Heart transplantation was performed firstly in 1967, but it became a valuable option in the 1980s... more Heart transplantation was performed firstly in 1967, but it became a valuable option in the 1980s, due to the availability of cyclosporine and of the technique for rejection monitoring by means of serial en- domyocardial biopsies. Post-transplant survival improved over the years, mainly due to a reduction in early mortality for infection or acute rejection. Expected 1-year and 5-year survivals are around 85% and 70%, respec- tively. During the past 20-30 years, better therapies for heart failure have been developed, leading to restriction of heart transplant candidacy to truly refractory heart failure. On the contrary, the crite- ria for donor acceptance have been liberalized, due to the discrepancy between heart transplant can- didates and available organs. It must be kept in mind that renal and/or hepatic insufficiency that may be a consequence of heart failure, pulmonary hypertension, and donor age, all remain risk factors for mortality after transplantation. In order to maintain...
Ventricular aneurysm as late complication has been described in cardiac sarcoidosis and occasiona... more Ventricular aneurysm as late complication has been described in cardiac sarcoidosis and occasionally in giant cell myocarditis. The images from the present case of ventricular aneurysm formation as a late complication of giant cell myocarditis underline a potential cause of sudden arrhythmic death in patients who survive this life-threatening condition in the absence of recurrent inflammation and with preserved left ventricular ejection fraction. Follow-up with cardiac magnetic resonance can detect small aneurysms, and an implantable cardioverter-defibrillator may be considered when this complication occurs.
Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over th... more Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over the past decade acute myocardial infarction treatment has changed because of new thrombolytic therapies and consequently, the value of exercise testing is under debate. The GISSI-2 database allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 patients, on average 28 days after randomisation. The test was not performed in 3923 patients because of contraindications. The test was judged positive for residual ischaemia in 26% of the patients, negative in 38%, and non-diagnostic in 36%. Among the patients with a positive stress test result, 33% had symptoms, whereas 67% had silent myocardial ischaemia. The mortality rate was 7.1% among patients who did not have an exercise test and 1.7% [correction of 7.1%] for those with a positive test, 0.9% for those who had a negative test, and 1.3% for those who did not have a diagnostic test. In the adjusted analysis, symptomatic induced ischaemia, submaximal positive result, low work capacity, and abnormal systolic blood pressure were independent predictors of 6-month mortality (relative risks [RR] 2.54, 95% CI 1.27-5.08, 2.28, 1.17-4.45, 2.05, 1.23-3.42, and 1.86, 1.05-3.31, respectively). However, when these factors were tested simultaneously, only symptomatic induced ischaemia and low work capacity were confirmed as independent predictors of mortality (RR Cox 2.07, 95% CI 1.02-4.23 and 1.78, 1.06-2.99, respectively). Patients with a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation should be devoted to the patients who cannot undergo exercise testing, because the potential to influence outcome appears to be much greater.
Tissue-type plasminogen activator (t-PA) is a serine protease that converts a zymogen plasminogen... more Tissue-type plasminogen activator (t-PA) is a serine protease that converts a zymogen plasminogen into an active serine protease, namely, plasmin. Plasmin is the proteolytic enzyme that degrades fibrin. In the absence of fibrin, e.g., in circulating plasma, t-PA activates plasminogen at a very slow rate. However, when fibrin is present, this activity is enhanced two to three orders of magnitude. As a consequence of these kinetic characteristics, plasmin is predominantly generated on the fibrin surface. This in turn results in a relative sparing of circulating fibrinogen and other plasma proteins to plasmin--mediated degradation. Following the demonstration of the potential of natural t-PA as a thrombolytic agent, an intensive effort was launched to enhance its production by recombinant DNA technology. The pharmacological action and the clinical efficacy of t-PA has been tested by several Authors in the treatment of acute myocardial infarction (AMI), and more recently, of pulmonary e...
A case of Staphylococcus aureus tricuspid valve endocarditis in a patient with permanent transven... more A case of Staphylococcus aureus tricuspid valve endocarditis in a patient with permanent transvenous VVI pacemaker and recurrent febrile episodes is described. Medical treatment was not effective, and only with surgical removal of the lead was the infection successfully treated.
Congestive heart failure is recognized as a major public health issue and is the leading cause of... more Congestive heart failure is recognized as a major public health issue and is the leading cause of death in western countries. Heart transplantation currently remains the gold standard option for end-stage heart failure patients. Heart transplantation is also one of the most limited therapies, not only with regard to the lack of donor hearts but also because of the surgical limitations inherent to the clinical aspects of this severely ill patient population. Mechanical circulatory support systems have been developed as effective adjuvant therapeutic options in these terminally ill patients. Over the past two decades, mechanical circulatory support devices have steadily evolved in the clinical management of end-stage heart failure, and have emerged as a standard of care for the treatment of acute and chronic heart failure refractory to conventional medical therapy. Future blood pumps should be smaller and totally implantable, as well as more efficient, biocompatible, and reliable.
European Journal of Heart Failure Supplements, 2003
Background: CRT improves functional status and may be prognosis in HF pts with interventricular c... more Background: CRT improves functional status and may be prognosis in HF pts with interventricular conduction delay. Ischemic etiology is known to portend a worse prognosis in the overall population of heart failure pts. Objective: To compare functional and clinical outcome after CRT in pts with HF of ischemic vs non-ischemic etiology. Methods: Clinical improvement (decrease of at least 1 NYHA functional class), mortality and change in functional parameters were analyzed in 106 patients (males 86%, mean age 61±9 years, NYHA class 3.0±0.5) who underwent CRT. The outcome was compared in pts with ischemic (n=38, 36%) and nonischemic (n=68, 64%) etiology, after a mean followup of 15±10 months. Regarding demographics and baseline clinical variables, nonischemic group had a higher prevalence of females (20.6% vs 2.6%; p<0.01) and greater left ventricular end-diastolic volume-LVEDV (p<0.05) than ischemic group. Mean age was higher in ischemic pts (65±9 vs 59±10 y., p<0.005). Results: Clinical improvement was more frequent (63/68, 93%) in pts with nonischemic than in pts with ischemic etiology (26/38, 68%, p<0.005). There were 3 deaths in nonischemic (4.4%) and 6 in ischemic pts (15.8%, p: n.s.). Both groups showed a significant increase of peak exercise VO2 (non isch from 12.2±3.8 to 14.3±3.7 ml/Kg/min, p<0.01; isch from 13.3±1.5 to 14.3±3.6 ml/Kg/min, p=0.03) and a significant decrease of LVEDV (non isch from 284±110 to 241±97 ml, p<0.001; isch from 233±66 to 216±64 ml, p=0.02) and of mitral regurgitation score (non isch from 2.1±1.1 to 1.7±0.9, p<0.01; isch from 1.9±0.9 to 1.5±0.7, p=0.02). Only nonischemic pts showed a significant increase of mean LV ejection fraction-LVEF (non isch from 25±7% to 31±8%, p<0.001; isch from 28±9% to 29±8%, p:n.s.). The subgroup of pts with ischemic etiology that experienced clinical improvement had a slight but not significant increase of LVEF (from 27±7 to 30±8; p=0.07). Inferences: After CRT, clinical and functional improvement occurs in the majority of pts with HF of any etiology, but less frequently in those with ischemic heart disease. Taking into account the regional structural and functional abnormalities that characterize this disease, it is possible that careful echo-guided search for the best pacing site at LV lead implantation would increase the rate of success of CRT in pts with HF of ischemic etiology.
European Journal of Heart Failure Supplements, 2003
Background: Symptoms and functional status in patients suffering from heart failure (HF)is often ... more Background: Symptoms and functional status in patients suffering from heart failure (HF)is often evaluated by qualitative and subjective methods. Aim of the study was to measure patient activity on objective and quantitative daily basis and correlate activity trend with standard outcome measurements. Methods: 39 pts (69% male, mean age 71.9±23.9 years old, mean NYHA class 2.9±0.8, mean ejection fraction (EF) 29.2±10.0%, mean QRS width 165.1±29.3 ms, with advanced HF have been implanted with an InSync III (Model 8042, Medtronic Inc.) biventricular stimulator. At each follow up (FU) visit, scheduled at 1, 4, 7 and 10 months after implant, diagnostics device memory and clinical data were collected. InSync III device continuously collects daily information concerning patient activity measuring the amount of time patient is active. In each minute, the number of activity sensor counts is accumulated and if the counts exceed a fixed threshold, the patient is considered active. The threshold is set so that continuous 70 steps per minute walk will be registered as active. Results: At 10 months FU NYHA class(2.0±1.0, P<0.001)and QRS duration(128.4±20.6 ms, P<0.0001)significantly decreased and EF significantly improved (37.2±11.6, P<0.01) in comparison with baseline. Patient activity data showed a significant increase from 52±81 minutes/day at pre-discharge to 235±128 minutes/day at 10 months FU(P<0.001). Mean activity trend is shown in the figure.
The Journal of Heart and Lung Transplantation, 2001
transgenes for human DAF. There are concerns about levels of immunosuppression and the risk of tr... more transgenes for human DAF. There are concerns about levels of immunosuppression and the risk of transmission of PERVs. The benefit of the transplant should not be out weighed by the risk of systemic disease. We report cases of a systemic vasculitis in the non-transplanted organs of xenograft recipients. Materials: Cynomologous monkeys received renal xenografts from pigs transgenic for hDAF. Several immunosuppressive protocols were used but were based on cyclosporin and steroids. Some received induction cyclophosphamide. Animals that died or sacrificed following transplantation had an autopsy with tissues submitted for histology. Results: In 208 transplants with survival Ͼ 1 day, 10 cases had histological evidence of a vasculitis. Median survival in all cases was 7 days against 29 days in the vasculitis cases. Tissue sampling protocols have changed and may under estimate the true frequency. The lesions showed fibrinoid necrosis of small muscular vessels with inflammatory cell debris. Lesions were seen in the submucosal vessels of the GI tract in 9 cases and in the pancreas in 1 case. Lesions were seen in the heart, adrenal and lymph node in 1 case each. 3 cases were associated with CMV infection but no inclusions were seen in relation to the vasculitic lesions. No occlusive thrombi or necrosis was seen.Immunohistochemistry showed &alpha-gal in the fibrinoid areas with detectable immunoglobulins in a number of cases. There was no correlation with severity of rejection.
The Journal of Heart and Lung Transplantation, 2009
Purpose: Functional mitral regurgitation (fMR) is associated with increased morbidity and mortali... more Purpose: Functional mitral regurgitation (fMR) is associated with increased morbidity and mortality in patients with idiopathic dilated cardiomyopathy (DCM). However, indication for mitral annuloplasty is still controversial. We examined the outcomes of restrictive mitral annuloplasty for DCM and the factors related to reverse remodeling. Methods and Materials: Twenty five patients with significant left ventricular (LV) dysfunction (LV end-diastolic dimension; LVEDD Ͼ/ϭ 60 mm, LV ejection fraction; LVEF Ͻ/ϭ 35%) and fMR (grade 3 or 4) due to DCM underwent restrictive mitral annuloplasty with downsizing of the mitral annulus using Phisyo-ring. Myocardial tissue was obtained from LV anterior wall by needle biopsy during the operation and the degree of cardiac fibrosis was measured. Results: During 18 Ϯ 13 months of follow up periods, there was 1 operative death due to multiple organ failure and 2 late deaths due to sepsis. New York Heart Association functional class improved from 3.4 Ϯ 0.6 to 2.0 Ϯ 0.8 (P Ͻ 0.0001). Postoperative echocardiography revealed grade 3 MR in 1 patient and grade 2 in 3. LVEDD decreased from 73.6 Ϯ 9.1 to 70.5 Ϯ 9.6 mm (P ϭ 0.0002) and mean pulmonary artery pressure decreased from 30.9 Ϯ 9.7 to 24.0 Ϯ 8.2 mmHg (P ϭ 0.0088). Cardiac index increased from 2.1 Ϯ 0.8 to 2.5 Ϯ 0.7 L/min/m 2 (P ϭ 0.0440). Histological examination of the LV anterior wall myocardium revealed degree of fibrosis ranged from 8.2% to 47.7% (mean 28.3 Ϯ 12.8%). Although there was no clinical hemodynamic or echocardiographic factor significantly correlates with LV reverse remodeling, the degree of myocardial fibrosis correlated significantly with decrease in LVEDD (P ϭ 0.0369, r ϭ -0.69) and pulmonary artery pressure (P ϭ 0.0478, r ϭ -0.63). Conclusions: Restrictive mitral annuloplasty improved symptoms and hemodynamics in patients with end-stage heart failure due to DCM. The degree of fibrosis of LV myocardium was the significant predictor of reverse remodeling after restrictive mitral annuloplasty.
The Journal of Heart and Lung Transplantation, 2004
Background: Cardiac resynchronization therapy (CRT) produces clinical benefit in heart failure (H... more Background: Cardiac resynchronization therapy (CRT) produces clinical benefit in heart failure (HF) patients (pts) with intraventricular conduction delay. Previous studies excluded pts who already had a pacing device. In this study, pts with denovo (DN) CRT were compared to those undergoing upgrade (UP) to CRT from standard pacing.
The Journal of Heart and Lung Transplantation, 2004
transplantation, and 5 bilateral lung transplantation with repair of the underlying defect. This ... more transplantation, and 5 bilateral lung transplantation with repair of the underlying defect. This represented 4%, 27% and 3 % of all patients undergoing heart, heart-lung and bilateral lung transplantation respectively. Patients undergoing heart transplantation either had complex abnormalities with low pulmonary artery pressure (n ϭ 37) or myocardial failure after previous reparative operations (n ϭ 23). Fourteen patients undergoing heart-lung transplantation had complex pulmonary atresia and 115 had CHD with pulmonary hypertension. The type of operation has been modified during the period under review to take account of the increasing scarcity of donor organs. Operative techniques are adapted according to the complexity of the underlying anatomy. In-hospital mortality was 20/60 (33%) for hearts, 41/115 (36%) in heart-lung transplantation for CHD and pulmonary hypertension and 12/14 (85%) for complex pulmonary atresia. There were no deaths in the five patients undergoing bilateral lung transplantation and repair. Major risk factors for early death in the heart-lung transplant group were complex pulmonary atresia, previous lateral thoracotomy and age greater than 35 years at transplant. Actuarial survival in the heart transplants was 60%, 54% and 46% at 1 year, 5 years, and 10 years respectively and 61%, 45% and 36% at 1 year, 5 years and 10 years respectively for heart-lung transplant patients with CHD and pulmonary hypertension. It is concluded that risk of early death is greater in patients with complex CHD undergoing heart transplantation than in patients with acquired heart disease. Thereafter survival in patients with CHD is similar to other patients undergoing heart or heart-lung transplantation.
The Journal of Heart and Lung Transplantation, 2007
angiography and adenosine nuclear tests that were obtained within 90 days from one another. We de... more angiography and adenosine nuclear tests that were obtained within 90 days from one another. We determined the ability of nuclear stress testing to accurately predict hemodynamically significant coronary lesions, defined as Ն70% angiographic stenosis. Results: The adenosine nuclear stress test was able to detect significant CAV in only 6 of 19 patients with significant coronary lesions. The test thus had a sensitivity of only 31.5%, but a specificity of 50%, a positive predictive value of 75%, and a negative predictive value of 13%. The adenosine nuclear study was also not effective in identifying patients with small vessel disease. Conclusions: Even with pharmacologic stress, nuclear perfusion imaging is a poor substitute for coronary angiography for the detection of CAV. The limitation in heart transplant patients is more likely due to the diffuse nature of the disease. Diffuse three vessel disease may produce balanced ischemia and consequently a false negative study.
In selected patients with postinfarction angina and impending reinfarction, thrombolysis with rec... more In selected patients with postinfarction angina and impending reinfarction, thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) or streptokinase is highly effective in avoiding a new myocardial infarction. To avoid major cardiac events, we treated 14 consecutive patients with thrombolytic therapy because of impending reinfarction with ECG ST-segment elevation. Thirteen patients received rt-PA (100 mg over 3 hours), and one patient received streptokinase (1.5 million IU over 1 hour). All patients had failed to respond to maximal medical therapy with intravenous nitrates, beta-blockers, Ca-antagonists, heparin, and opiates. In all patients, clinical and ECG signs of acute ischemia resolved completely within 1 hour after beginning thrombolysis, and no patient developed biochemical markers of myocardial infarction. Ten patients underwent coronary angiography: five had three-vessel disease, two had two-vessel disease, and three had one-vessel disease. The culprit lesion was located in the left anterior descending artery in eight cases and the right coronary artery in two. No patient showed intracoronary thrombus. Four patients underwent successful, semiurgent percutaneous transluminal coronary angioplasty; three received an elective and two an urgent coronary artery bypass graft. Thrombolysis (or repeated thrombolysis) is effective in selected patients with clinical ECG signs of impending reinfarction. It can temporarily stabilize the condition of many patients, thus allowing safer mechanical revascularization to be performed.
Symptomatic heart failure is preceded by a somewhat prolonged asymptomatic stage in many patients... more Symptomatic heart failure is preceded by a somewhat prolonged asymptomatic stage in many patients. The number of patients with asymptomatic heart dysfunction is about 4-fold greater than the number of patients with clinically overt heart failure. Pharmacologic treatment with angiotensin-converting enzyme inhibitors and -blockers (in particular carvedilol) of asymptomatic patients with systolic left ventricular (LV) dysfunction can prevent or delay the occurrence of symptoms and reduce mortality in the long term. Thus, it would be of utmost importance to recognize and appropriately treat these patients before they develop heart failure symptoms. The cost-effectiveness of screening for asymptomatic heart dysfunction in the general population and in cohorts at risk has not been extensively evaluated. A normal electrocardiogram has a high negative predictive value in patients at risk. Echocardiography is the best tool for diagnosis and characterization of heart dysfunction, but extensive use is limited by availability and cost. Natriuretic peptides (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) are very sensitive markers of heart dysfunction and volume overload, and their measurement has been proposed as a first-line test to select patients who need echocardiography. The definition of the etiology of LV dysfunction-in particular, of the ischemic etiology-has prognostic and therapeutic implications. In addition to revascularization, pharmacologic treatment with antiplatelets and statins is helpful in preventing new ischemic events and the development of heart failure. The prevention, or at least the delay, of clinical manifestations of heart failure is strongly related to an effective approach to the asymptomatic stage. Therefore, it is important to educate the entire medical community, particularly physicians in the primary care setting, about recognition and treatment of these patients. ᮊ2003 by Excerpta Medica, Inc. Am J Cardiol 2003;91(suppl):4F-9F
Heart transplantation was performed firstly in 1967, but it became a valuable option in the 1980s... more Heart transplantation was performed firstly in 1967, but it became a valuable option in the 1980s, due to the availability of cyclosporine and of the technique for rejection monitoring by means of serial en- domyocardial biopsies. Post-transplant survival improved over the years, mainly due to a reduction in early mortality for infection or acute rejection. Expected 1-year and 5-year survivals are around 85% and 70%, respec- tively. During the past 20-30 years, better therapies for heart failure have been developed, leading to restriction of heart transplant candidacy to truly refractory heart failure. On the contrary, the crite- ria for donor acceptance have been liberalized, due to the discrepancy between heart transplant can- didates and available organs. It must be kept in mind that renal and/or hepatic insufficiency that may be a consequence of heart failure, pulmonary hypertension, and donor age, all remain risk factors for mortality after transplantation. In order to maintain...
Ventricular aneurysm as late complication has been described in cardiac sarcoidosis and occasiona... more Ventricular aneurysm as late complication has been described in cardiac sarcoidosis and occasionally in giant cell myocarditis. The images from the present case of ventricular aneurysm formation as a late complication of giant cell myocarditis underline a potential cause of sudden arrhythmic death in patients who survive this life-threatening condition in the absence of recurrent inflammation and with preserved left ventricular ejection fraction. Follow-up with cardiac magnetic resonance can detect small aneurysms, and an implantable cardioverter-defibrillator may be considered when this complication occurs.
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Papers by Fabio Turazza