Left Atrial Appendage Thrombosis and Persistent Atrial Fibrillation: combined Treatment with a Totally Thoracoscopic Approach

Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage.

We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up.

This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques.

Prediction of mortality in patients with implantable defibrillator using CHADS2 score: data from a prospective observational investigation

BACKGROUND

CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke/TIA) score has been validated as a risk stratification score to predict stroke in patients with atrial fibrillation (AF). The objective of this analysis was to assess whether patient risk factors, in particular CHADS2 score, identified patients at risk of mortality.

METHODS

821 patients with an implantable cardioverter defibrillator were prospectively followed-up in 11 cardiology centers. Patients were grouped in 3 groups according to pre-specified risk classes: low (CHADS2 = 0), moderate (CHADS2 = 1, 2), and high (CHADS2 = 3-6). Information on clinical status and events, were collected during scheduled and unscheduled follow-up visits. Deaths were retrieved from medical records, or through the Regional Office of Vital Statistics.

RESULTS

Over a mean follow-up of 44±26 months, 135 deaths occurred in the overall population: 6 (7.7%) in the low-risk population, 69 (13.8%) in moderate-risk patients and 60 (24.6%) in high-risk patients. Kaplan-Meier estimated of patient survival were significantly different in 3 patients groups (93.0%, 90.1%, 78.5% in low, moderate and high risk patients respectively, at 4 years P<0.001). A sub-analysis on patients without history of AF showed similar results. Multivariate regression analysis adjusted for baseline characteristics confirmed the high risk status (HR 1.88, 95% CI 1.27-2.80; P = 0.002) as an independent predictor of mortality adjusted for the baseline characteristics.

CONCLUSIONS

In our multicenter research, the long-term mortality was higher in patients with high CHADS2 score than in those with lower risk score regardless the presence of history of AF. CHADS2 score could be considered a toll to predict all causes mortality.

Paroxysmal atrial fibrillation triggered by a monomorphic ventricular couplet in a patient with acute coronary syndrome

Atrial fibrillation is a common arrhythmia in patients suffering from acute myocardial infarction, however its pathophysiological mechanisms are not fully understood. We describe the unusual case of a 76-year old woman admitted for non-ST-segment elevation myocardial infarction, who developed multiple episodes of paroxysmal atrial fibrillation triggered by monomorphic ventricular couplets. Beta-blocking and amiodarone therapy resulted efficacious in preventing arrhythmic recurrences. We then discuss the possible arrhythmogenic mechanisms, with special emphasis on the unique electrophysiological, hemodynamic, cellular and anatomical milieu created by acute myocardial ischemia.

Relative predispositional effects of HLA class II DRB1-DQB1 haplotypes and genotypes on type 1 diabetes: a meta-analysis

The direct involvement of the human leukocyte antigen class II DR-DQ genes in type 1 diabetes (T1D) is well established, and these genes display a complex hierarchy of risk effects at the genotype and haplotype levels. We investigated, using data from 38 studies, whether the DR-DQ haplotypes and genotypes show the same relative predispositional effects across populations and ethnic groups. Significant differences in risk within a population were considered, as well as comparisons across populations using the patient/control (P/C) ratio. Within a population, the ratio of the P/C ratios for two different genotypes or haplotypes is a function only of the absolute penetrance values, allowing ranking of risk effects. Categories of consistent predisposing, intermediate ('neutral'), and protective haplotypes were identified and found to correlate with disease prevalence and the marked ethnic differences in DRB1-DQB1 frequencies. Specific effects were identified, for example for predisposing haplotypes, there was a statistically significant and consistent hierarchy for DR4 DQB1*0302s: DRB1*0405 =*0401 =*0402 > *0404 > *0403, with DRB1*0301 DQB1*0200 (DR3) being significantly less predisposing than DRB1*0402 and more than DRB1*0404. The predisposing DRB1*0401 DQB1*0302 haplotype was relatively increased compared with the protective haplotype DRB1*0401 DQB1*0301 in heterozygotes with DR3 compared with heterozygotes with DRB1*0101 DQB1*0501 (DR1). Our results show that meta-analyses and use of the P/C ratio and rankings thereof can be valuable in determining T1D risk factors at the haplotype and amino acid residue levels.

Severe ventricular dysrhythmias and silent ischemia during infusion of the antimetabolite 5-fluorouracil and cis-platin

The antimetabolite 5-fluorouracil is frequently used in the therapy of various malignancies. Cardiotoxicity has frequently been described during treatment, but there is no common agreement on the need to perform cardiovascular monitoring of patients during 5-fluorouracil administration. We report the case of a young patient with an head-neck cancer on whom a continuous electrocardiogram recording was performed, documenting serious ventricular dysrhythmias in the presence of myocardial ischemia during 5-fluorouracil and cis-platin infusion.

Distribution of killer cell immunoglobulin-like receptors genes in the Italian Caucasian population

Background

Killer cell immunoglobulin-like receptors (KIRs) are a family of inhibitory and activatory receptors that are expressed by most natural killer (NK) cells. The KIR gene family is polymorphic: genomic diversity is achieved through differences in gene content and allelic polymorphism. The number of KIR loci has been reported to vary among individuals, resulting in different KIR haplotypes. In this study we report the genotypic structure of KIRs in 217 unrelated healthy Italian individuals from 22 immunogenetics laboratories, located in the northern, central and southern regions of Italy.

Methods

Two hundred and seventeen DNA samples were studied by a low resolution PCR-SSP kit designed to identify all KIR genes.

Results

All 17 KIR genes were observed in the population with different frequencies than other Caucasian and non-Caucasian populations; framework genes KIR3DL3, KIR3DP1, KIR2DL4 and KIR3DL2 were present in all individuals. Sixty-five different profiles were found in this Italian population study. Haplotype A remains the most prevalent and genotype 1, with a frequency of 28.5%, is the most commonly observed in the Italian population.

Conclusion

The Italian Caucasian population shows polymorphism of the KIR gene family like other Caucasian and non-Caucasian populations. Although 64 genotypes have been observed, genotype 1 remains the most frequent as already observed in other populations. Such knowledge of the KIR gene distribution in populations is very useful in the study of associations with diseases and in selection of donors for haploidentical bone marrow transplantation.

Identification of a new allele, HLA-DRB5*0113, through three different molecular biology techniques

A new HLA-DRB5 allele, HLA-DRB5*0113, has been identified in an Italian patient during routine HLA typing in order to activate a bone marrow donor search. HLA typing was performed by different molecular biology techniques, and the results showed that the HLA-DRB5*0113 allele differs from HLA-DRB5*010101 allele for three nucleotide substitutions at codons 57 (GAC-->GAT; Asp) and 58 (GCT-->GAG; Ala-->Glu) of exon 2.

Cardiac resynchronization therapy as an 'alternative' approach to a non-operable severe aortic stenosis with left ventricular dysfunction

Severe symptomatic aortic stenosis (AS) is an indication for surgical replacement of the aortic valve in adults. Patients are often affected by comorbidities, and the surgical indication is sometimes problematic. Non-surgical techniques have been developed during the past few years, though their roles have not yet been established. Cardiac resynchronization therapy has been shown to be effective in selected patients, but no data yet exist on the role of this therapy in AS patients. The case is presented of a patient with non-operable severe symptomatic AS and cardiac dissynchrony who showed significant improvement following the implantation of a biventricular pacemaker.

Hepatitis C virus-associated oral lichen planus: is the geographical heterogeneity related to HLA-DR6?

BACKGROUND

The association between hepatitis C virus (HCV) and oral lichen planus (OLP) is more common in the Mediterranean area and Japan, possibly because of immunogenetic factors.

METHODS

Intermediate-resolution HLA-DRB typing by hybridization with oligonucleotide probes was performed in 31 Italian OLP patients with HCV infection, in 45 Italian OLP and in 48 British OLP patients without HCV infection. As healthy controls we included data from 145 unrelated Italian and 101 unrelated British bone marrow donors.

RESULTS

Italian HCV+ve OLP patients possessed the HLA-DR6 allele more frequently than Italian and British OLP patients without HCV infection (51.6% vs. 17.7% vs. 16.7%; P corrected = 0.028 and 0.017, respectively). There was no difference in the frequency of the HLA-DR6 allele between Italian and British control subjects.

CONCLUSIONS

The present data suggest that HLA-DR6 may be responsible for the peculiar geographic heterogeneity of the association between HCV and OLP.

[Long QT and torsade de pointes in a patient with acquired human immunodeficiency virus infection in multitherapy with drugs affecting cytochrome P450]

In acquired human immunodeficiency virus (HIV) infection, a long depolarization period at ECG may be the consequence of cardiac complications due to viral myocarditis or cardiomyopathy or indirectly due to autonomic neuropathy, or sometimes resulting from pharmacological treatments. Several drugs administered for direct treatment of HIV disease or its complications, such as antiretrovirus, fluconazole, and antibiotics, may induce ventricular arrhythmias due to long QT prolonged depolarization period. Also methadone, frequently associated with HIV therapy to treat patients with opiate addiction, is described in the literature to have cardiac inotropic effects. It has also the potential to increase the QT period and to develop ventricular torsade de pointes, primarily through interference with the rapid component of the delayed rectifier potassium ion current. Moreover, the use of methadone associated with other inhibitors of cytochrome P450 might increase plasma concentrations and contribute to methadone cardiac toxicity. We report the case of an HIV patient receiving antiretroviral treatment, fluconazole and high-dose methadone, who suddenly complained of vertigo, dizziness, pre-syncope and syncope due to severe ventricular arrhythmias that disappeared after discontinuation of all treatments.

A new allele, HLA-DRB4*010304

We report here the identification of a novel DRB4*01 allele, DRB4*010304, found in a patient waiting for a liver transplantation. The new allele was detected during a routine DNA-based HLA typing. Sequencing confirmed that the new allele is identical to DRB4*01030101 at exon 2 except for position 216 where the new allele has a T instead of a C.

Genotyping for cytokine polymorphisms: allele frequencies in the Italian population

It has been demonstrated that many cytokine genes [e.g. tumour necrosis factor alpha (TNF-alpha) and interleukin 10 (IL-10)] show polymorphisms which may affect gene transcription, causing individual variations in cytokine production. The majority of polymorphisms described are single nucleotide polymorphisms (SNPs). In 140 healthy Italian subjects, the allelic and genotype frequencies were determined for the cytokine genes IL-1 alpha (T/C -889), IL-1 alpha (C/T -511, T/C +3962), IL-12 (C/A -1188), interferon (IFN)-gamma (A/T UTR 5644), transforming growth factor (TGF)-alpha (C/T codon 10, G/C codon 25), TNF-alpha (G/A -308, G/A -238), IL-2 (T/G -330, G/T +166), IL-4 (T/G -1098, T/C -590, T/C -33), IL-6 (G/C -174, G/A nt565), IL-10 (G/A -1082, C/T -819, C/A -592), IL-1R (C/T pst11970), IL-1RA (T/C mspa111100) and IL-4RA (G/A +1902). All typings were performed with PCR-SSP assays. Allele and genotype frequencies and linkage disequilibria were calculated and compared with those of other populations.

Usefulness of exercise test in selected patients coming to the emergency department for acute chest pain

BACKGROUND

The management of patients with acute chest pain is a common and difficult challenge for clinicians. In our emergency department (ED) a systematic protocol that involves the use of the exercise test for the management of patients with chest pain of suspected cardiac origin is presently running. The aim of the present study was to evaluate the feasibility of such a test in this setting, in terms of the safety and satisfactory follow-up of these patients discharged home.

METHODS

Patients with chest pain lasting < or = 24 hours, aged > 18 years, without a history of trauma or of any other evident medical cause of chest pain and without high-risk characteristics were included in the present study. These patients, defined as low-risk patients for acute coronary events on admission, were evaluated in the ED area and submitted to serial ECG and blood sampling for the determination of the creatine kinase-MB mass and troponin I serum levels on admission and at 6 and 12 hours after admission. A symptom-limited maximal exercise was performed in the patients with a negative clinical observation and typical chest pain or atypical chest pain but multiple coronary risk factors.

RESULTS

In the year 2000, 1370 patients were evaluated in the ED for chest pain. In 150 (11%) an exercise test was performed. The test was positive in 24 patients (16%). The criteria for a positive test were only clinical in 3 patients, only ECG in 13 patients, and both in 8 patients. Inconclusive tests were observed in 27 patients (18%) and the test was negative in 99 patients (66%). There were no complications during the exercise test. At a median follow-up of 237 days (range 11-443 days), 11 clinical events were recorded (4 acute coronary syndromes and 7 revascularization procedures). Patients with a non-negative exercise test had a significantly shorter event-free survival (p < 0.005).

CONCLUSIONS

The exercise test performed in selected patients coming to the ED with acute chest pain is safe and useful for further risk assessment.

[Safety and effectiveness of dual chamber pacing in patients over 80 years of age with previous episodes of paroxysmal atrial fibrillation]

BACKGROUND

Dual chamber pacing (DDD) in the elderly is still a controversial issue because of its short life expectancy and the risk of atrial fibrillation. The aim of the study was 1) to evaluate the cumulative survival and the events capable of modifying it, 2) to evaluate the stability of sinus rhythm, and 3) to try to identify patients who are at a higher risk of developing permanent atrial fibrillation after DDD implantation. We evaluated clinical, electrophysiological and pacing parameters at the time of implantation.

METHODS

We examined retrospectively a group of 135 consecutive patients who were > 80 years old and who were treated with DDD in the last decade.

RESULTS

At the time of evaluation (mean 33.51 +/- 27.10 months, range 4-148 months) after DDD implantation, 72% of patients were still alive. Sinus rhythm was documented in 96 (71%) patients (group A). Thirty-nine (29%) patients (group B) developed atrial fibrillation after a mean period of 28.56 +/- 30.9 months (range 1-125 months). The right atrial endocavitary signal amplitude was lower in group B compared to that observed in group A (2.6 +/- 1.16 vs 3.27 +/- 1.91 mV). The pacing and sensing atrioventricular delay were not statistically different in both groups. The minimum heart rate was higher in patients who developed atrial fibrillation (64.53 +/- 7.7 vs 67.7 +/- 5.72 b/min respectively in group A and in group B, p = 0.02). Group B patients had a higher rate of atrial fibrillation pre-implantation episodes. The incidences of sick sinus disease and of atrioventricular nodal disease were similar in both groups.

CONCLUSIONS

In elderly patients the benefits of DDD are maintained for a long period of time before the development of atrial fibrillation. Episodes of atrial fibrillation prior to DDD, apart from sinus dysfunction alone, are predictive of the development of a permanent atrial fibrillation. Permanent atrial fibrillation does not seem to reduce life expectancy. A higher minimum heart rate does not seem to prevent atrial fibrillation. The capability of recording a right atrial signal amplitude > 3 mV seems to identify those patients with a lower risk of developing atrial fibrillation.

[Proarrhythmic effects of propafenone in a woman with hepatopathy: is it always a simple drug in clinical practice?]

A 65-year-old woman with a history of alcoholic liver disease and presenting with fever and vomiting was admitted to an internal medicine unit. In view of recent atrial fibrillation with inadequate heart rate control, digoxin and propafenone were included in the therapeutic regimen. After a few days sinus rhythm was restored but suddenly ventricular arrhythmias with the characteristics of a non-responsive electrical storm arose shortly following the appearance of clinical symptoms of drug intoxication.

Transesophageal electrical cardioversion of persistent atrial fibrillation: a new approach for an old technology

BACKGROUND

Low energy intracardiac cardioversion may be considered the elective, alternative method for the acute restoration of sinus rhythm when direct current cardioversion fails or is contraindicated. Transesophageal cardioversion is a further alternative method for the recovery of sinus rhythm and obviates the potential complications of the low energy intracardiac cardioversion venous approach.

METHODS

The present prospective study including 30 patients (21 males, 9 females, mean age 65.1 years, range 52-76 years), with persistent atrial fibrillation (mean duration 4.3 months), was undertaken in order to further evaluate, with regard to transesophageal cardioversion: 1) the acute efficacy, 2) the patient acceptance of the procedure, 3) the preferable choice among direct current cardioversion, low energy intracardiac cardioversion and transesophageal cardioversion, 4) the time required to perform the procedure, 5) the incidence of complications, and 6) the persistence of sinus rhythm after 1 month.

RESULTS

Sinus rhythm was acutely restored in 29 patients (96.7%). Discomfort induced by the electrical shock was minimal or mild in most patients (75.8%). Transesophageal cardioversion was usually preferred by patients who had been previously submitted to direct current cardioversion or low energy intracardiac cardioversion. The mean total time required to perform the procedure was 107.9 min. No complications related to the procedure occurred. In spite of adequate pharmacological prophylaxis of atrial fibrillation only 41.4% of patients were in sinus rhythm 1 month after successful transesophageal cardioversion.

CONCLUSIONS

Transesophageal cardioversion may be considered a very effective, well accepted and non-time consuming procedure for the short-term restoration of sinus rhythm. The incidence of complications is low.

[Hemodynamics and clinical data in chronic coronary disease with severe left ventricular systolic dysfunction]

To elucidate how symptoms and signs of chronic heart failure are related to the filling pressure and cardiac output at rest, 58 patients (55 males, 3 females, mean age 57 +/- 9 years, range 30-75) with left ventricular ejection fraction (LVEF) < or = 30% and a lesion > or = 50% on a major coronary branch have been selected from patients submitted in 1985-1993 to a complete right and left cardiac catheterization including ventriculography and coronary angiography. Patients with recent myocardial infarction (MI), unstable angina, associated heart diseases or recent changes in body weight and in diuretic therapy were excluded. Clinical data were obtained at cardiac catheterization time from history, physical examination, chest X-ray and ECG. Patients with angina as limiting symptom were excluded from NYHA functional classification. Pulmonary venous congestion (PVC) was defined on X-ray as: absent, venous redistribution, interstitial pulmonary edema (IPE). Mean pulmonary capillary wedge pressure (PCWP) was recorded under fluoroscopy and cardiac index was measured by the Fick method. On the whole group, 96% of patients had had one or more MI (on ECG necrosis was anterior in 58%, inferior in 9%, anterior and inferior in 26%), 69% were in NYHA functional class III or IV, 54% had IPE and 45% had mitral regurgitation. 71% were under treatment with digitalis, 74% with diuretics and 39% with ACE-inhibitors. PCWP was correlated with LVEDV (r = 0.34; p < 0.001) but neither with LV mass nor with LV mass/volume ratio. It was significantly higher (p < 0.01) in patients with mild-moderate mitral regurgitation, in patients with necrosis involving both anterior and inferior walls (26 +/- 6 vs 21 +/- 8 mmHg in patients with single wall necrosis, p < 0.05) and in patients with multiple MI (26 +/- 7 vs 20 +/- 8 mmHg in patients with no or single MI, p < 0.02). Moreover, it was neither correlated with functional classification nor with PVC: of patients with PCWP > 24 mmHg, 14% were in II NYHA functional class and 21% had no PVC while of patients with PCWP < 15 mmHg, 36% were in NYHA functional class IV and 7% had IPE. Cardiac index was reduced below 2.3 l/min/m2 in 21% of patients: these patients had increased pulmonary (p < 0.0002) and systemic (p < 0.0001) vascular resistance, increased systolic (p < 0.001) and diastolic (p < 0.01) pulmonary artery pressure and reduced LVEF (p < 0.01) and right ventricular ejection fraction (p < 0.03). Furthermore, on the whole patients an inverse correlation was found between cardiac index and functional classification (r = -0.42; p < 0.01). The reliability of NYHA functional class IV, physical signs of heart failure and IPE for estimating PCWP > 24 mmHg and cardiac index < 2.3 l/min/m2 was rather limited although high specificity was shown for gallop sounds (92 and 97%) and jugular vein distension (88 and 97%). In conclusion, in coronary patients with chronic severe LV systolic dysfunction a mismatch between clinical data and central hemodynamics is not rare. The reliability of functional class, X-ray PVC and physical signs to predict central hemodynamics in fairly limited.