Hospital Chronicles (E-Journal)
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Asymptomatic Valvular Heart Disease: Indications and Timing for Surgery
Get PDFPatients who have severe aortic stenosis and remain asymptomatic is an issue of great interest and controversy. The reason of the argument is that on one side many physicians believe that irreversible myocardial damage and fibrosis may develop during a prolonged asymptomatic stage and therefore delayed aortic valve replacement will not have ideal results [1]. On the other side early surgery is associated with perioperative mortality and morbidity and significant long-term morbidity (2%/year) and mortality (1%/year), which combined together, exceed the possibility of sudden death (1%/year) from the aortic stenosis itself [2,3]. Therefore we should try to identify patients who may be at high risk of sudden death or patients who are ???pseudo-asymptomatic?? by limiting their gradual daily physical activity. Exercise stress test within a hospital environment is a useful tool to reveal these groups of patients.In brief, asymptomatic patients with severe aortic stenosis who have abnormal stress test or left ventricular systolic dysfunction or excessive left ventricular hypertrophy or very tight aortic stenosis, should be offered the benefit of aortic valve replacement
Transcatheter Closure of Large-Sized Coronary Artery Fistula
Get PDFWe report our experience with the use of AMPLATZER?? Vascular Plug for the closure of coronary artery fistulas. Three patients (age: 3, 12, 14 years) were diagnosed with coronary fistulas (pulmonary-to-systemic blood flow ratio: 1.5 to 3). Two of the fistulas originated each, from the proximal right and left coronary artery and had maximal diameter 9 and 10 mm respectively; their narrowest diameter (6 mm) was proximal to their entrance into the right atrium creating a form of a saccular aneurysm.The third fistula (maximal diameter: 16 mm) originated from the circumflex artery and entered the right atrium with unobstructed flow (narrowest diameter: 8 mm). Interventional closure was considered optimal and the decision was made to use devices sized twice the size of the narrowest diameter of the fistulas (12, 12 and 16 mm respectively). An arterio-venous loop was established through the fistula by snaring an exchange guide-wire. All plugs were implanted from the femoral vein with the use of a seven or eight French guide catheter, reaching the narrowest segment of the fistula and leading to complete closure of the two fistulas, immediately after the procedure. The fistula arising from the circumflex artery that received the largest plug continued to have residual flow up to 12 months after the procedure, when follow-up echocardiography revealed its complete occlusion. We present and consider the use of the AMPLATZER?? Vascular Plug as a safe and effective method for the transcatheter closure of large-sized coronary fistulas. The plug potentially offers an alternative method to coil occlusion techniques as well as open heart surgery
Electrocardiographic Changes Associated With Right-sided Pneumothorax
Get PDFSeveral electrocardiographic (ECG) changes have been described with pneumothorax, most often left-sided. We present a case of spontaneous right-sided pneumothorax, presenting with an ECG suggesting an old myocardial infarction. A chest X-ray confirmed the diagnosis of pneumothorax, while an echocardiogram and serial cardiac enzyme testing excluded myocardial infarction. ECG changes returned to normal after chest tube insertion. Physicians should be familiar with the ECG changes that can be caused by pneumothorax in order to avoid diagnostic and therapeutic pitfalls
Revascularization of the Infarct-related Artery: Never Too Late?
Get PDFDuring the early phase of an acute myocardial infarction (MI), current consensus is that reperfusion of the infarct-related artery (IRA) should be implemented as soon as possible, more effectively accomplished via percutaneous coronary intervention (PCI). The clinical approach to the occluded IRA late after MI remains controversial, but current practice shows a strong trend in favor of PCI, which is based on the late open artery hypothesis. However, late PCI on IRAs also has the potential for harm from procedure-related complications. An attempt is made herein to critically overview the current data on this important topic, mainly based on recent meta-analyses with somewhat diverging results, indicating that clinical judgment and an individualized approach still remains a valid guide
Fixed Combinations in Antihypertensive Therapy
Get PDFAs we stand in the early years of the 21st century, with hundreds of antihypertensive drugs at our disposal, it is difficult to believe that 60 years ago there was absolutely nothing available for the treatment of hypertension. In fact, it was not even universally accepted that the ???benign?? or ???essential?? hypertension needed to be treated, unless it entered the malignant phase. At that point, it was treated with desperate measures, such as pyrogens or poisons causing circulatory shock or with radical surgical procedures, such as severance of sympathetic tracts or bilateral adrenalectomy
Renal Artery Intervention
Get PDFRenal artery stenosis (RAS), hypertension and renal insufficiency (RI) are each frequently present especially in the elderly population. RAS is often present without any clinical signs or symptoms and even when hypertension or renal insufficiency are also present, they may be coincidentally rather than causally related. However, when RAS is hemodynamically or physiologically significant, it is one of the few potentially reversible causes of RI and hypertension.The challenge for physicians is to identify patients with RAS who would benefit from renal revascularization, whether by interventional techniques or open surgery. RAS is often clinically silent, at least until it becomes hemodynamically significant when it can produce renal vascular hypertension (RVH) or RI
Iron Overload and Myocardial Restriction
Get PDFHeart failure still remains the main cause of death in β-thalassemia, despite the progress, which was made by intensification of iron chelation therapy. Iron myocardial deposition, due to regular blood transfusions, can cause congestive heart failure as a result of left- or right-sided heart failure combined with left ventricular myocardial restriction. Regular and intense chelation therapy has improved quality of life and survival by decreasing secondary hemochromatosis. However, heart failure has not been prevented despite the intensification of iron chelation therapy. Acute myocarditis in β-thalassemia major has been reported to contribute to heart failure in addition to iron overloading. However, apart from myocarditis which may lead to immune mediated chronic left ventricular dysfunction and failure, other factors acting through immunologic or genetically defined mechanisms might also affect the development of left sided heart failure. Multiple transfusions represent a repetitive antigenic stimulus together with iron chelation therapy itself. In this brief overview, the pathogenetic mechanisms of myocardial involvement and heart failure in β-thalassemia major are discussed
Reperfusion in Acute Myocardial Infarction: How is the Future Shaping up?
Get PDFCurrent evidence from several clinical trials indicates that primary angioplasty in patients with acute myocardial infarction (AMI) appears superior reperfusion therapy to immediate thrombolysis, even when transfer to an angioplasty center is necessary. Thus, organization of ambulance systems and adequate angioplasty facilities appears to be the key issue in providing the most effective contemporary reperfusion therapy for AMI. Furthermore, on-site primary coronary angioplasty in high-risk AMI patients at hospitals with no cardiac surgery on-site is nowdays considered safe, effective, and faster than angioplasty after transfer to a surgical facility. Randomized trials have demonstrated the superiority of primary angioplasty with stent implantation over balloon angioplasty alone in the treatment of AMI, including patients with diabetes. Stent use has been associated with significant decreases in length of stay, major adverse cardiovascular events, and in-hospital mortality. Finally, because of the risk of stent thrombosis, the issue of whether drug-eluting stents are safe or even more beneficial than bare-metal stents in patients with AMI, as in other non-AMI patient groups, remains uncertain, although preliminary data seem to favour the use of drug-eluting stents
Cardiac Pacemaker (If) Current: Physiological and Pharmacological Properties
Get PDFMammalian sinoatrial node (SAN) cells, the natural pacemaker cells of the heart, have an action potential characterized by the presence of a special phase, the slow diastolic (pacemaker) depolarization (phase 4), which drives pacemaker activity and has therefore attracted the interest of generations of cardiac physiologists. What is the basis of the pacemaker depolarization? Here the features of the “funny” (If) current of pacemaker cells and its involvement in the generation and autonomic regulation of heart rate are briefly addressed. There is also addressed the involvement of If in the pharmacological control of cardiac chronotropism, and how defective “funny” channels can be responsible for inherited heart rhythm disturbances