Electrocardiographic and Echocardiographic Predictors of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy

Background

Patients with hypertrophic cardiomyopathy (HCM) have an increased prevalence of atrial fibrillation (AF) compared to the general population, and left atrium (LA) remodeling is strongly correlated with the risk of AF. This prospective, monocentric study aimed to assess the role of LA electrocardiographic and echocardiographic (structural and functional) parameters in predicting the risk for incident AF in patients with HCM.

Methods and Results

The study population consisted of 126 HCM patients in sinus rhythm (52.6 ± 16.2 years, 54 men), 118 of them without documented AF. During a median follow-up of 56 (7–124) months, 39 (30.9%) developed a new episode of AF. Multivariable analysis showed that LA booster pump function (assessed by ASr, HR = 4.24, CI = 1.84–9.75, and p = 0.038) and electrical dispersion (assessed by P wave dispersion – Pd, HR = 1.044, CI = 1.029–1.058, and p = 0.001), and not structural parameters (LA diameter, LA volume) were independent predictors of incident AF. Seventy-two patients had a LA diameter < 45 mm, and 16 of them (22.2%) had an AF episode during follow-up. In this subgroup, only Pd emerged as an independent predictor for incident AF (HR = 1.105, CI = 1.059–1.154, and p = 0.002), with good accuracy (AUC = 0.89).

Conclusion

Left atrium booster pump function (ASr) and electrical dispersion (Pd) are related to the risk of incident AF in HCM patients. These parameters can provide further stratification of the risk for AF in this setting, including in patients considered at lower risk for AF based on the conventional assessment of LA size.

Carotid arterial stiffness is increased and related to left ventricular function in patients with hypertrophic cardiomyopathy

Aims

To assess the carotid mechanical properties in patients with hypertrophic cardiomyopathy and the relation between arterial stiffness and left ventricular function in this setting.

Methods and results

We have prospectively enrolled 71 patients (52 ± 16 years, 34 men) with hypertrophic cardiomyopathy, divided into two groups depending on the presence (46 patients) or absence (25 patients) of cardiovascular risk factors associated with increased arterial stiffness. Twenty-five normal subjects similar by age and gender with hypertrophic cardiomyopathy patients without risk factors formed the control group. A comprehensive echocardiography was performed in all subjects. Carotid arterial stiffness index (β index), pressure–strain elastic modulus, arterial compliance, and pulse wave velocity were also obtained using an echo-tracking system. β index, pulse wave velocity, and pressure–strain elastic modulus were significantly higher in hypertrophic cardiomyopathy patients without risk factors compared to controls. After linear regression analysis, the increase in carotid β index was independently correlated with the presence of hypertrophic cardiomyopathy [beta = 0.49, 95% confidence interval (CI) = 1.04–3.02; P < 0.001]. In the entire hypertrophic cardiomyopathy population arterial stiffness parameters correlated with age, gender, hypertension degree, presence of hypercholesterolaemia, and the E/e′ ratio. In multivariable analysis, β index (beta = 0.36, 95% CI = 0.32–1.25; P = 0.001), global left ventricular longitudinal strain, and the presence of left ventricular outflow tract obstruction were independently correlated with the E/e′ ratio.

Conclusion

In patients with hypertrophic cardiomyopathy arterial stiffness is increased independently of age or presence of cardiovascular risk factors. Carotid artery stiffness is independently related to left ventricular filling pressure, increased arterial stiffness representing a possible marker of a more severe phenotype.

Pulmonary veno-occlusive disease: a rare cause of pulmonary hypertension in systemic sclerosis. Case presentation and review of the literature

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary arterial hypertension (PAH). Because of the similar clinical picture of dyspnea on exertion and signs of right heart failure, PVOD is difficult to distinguish from idiopathic PAH. However, the distinction is mandatory because PVOD has a worse prognosis and, more importantly, the administration of PAH specific therapy (vasodilators) can precipitate severe acute pulmonary oedema. We present a challenging case of PAH in a patient with systemic sclerosis in whom a marked decrease in functional capacity after the initiation of bosentan therapy led to the diagnosis of PVOD. Management of PVOD patients is challenging and referral for lung transplantation should be done at the moment of diagnosis.

Impact of metabolic syndrome traits on cardiovascular function: should the Adult Treatment Panel III definition be further stratified?

AIMS

The aims of the study were to evaluate whether a further classification of metabolic syndrome according to the number of traits (based on the Adult Treatment Panel III definition) could better explain the impact on cardiovascular remodeling and function, and to assess the role of single metabolic syndrome components in this regard.

METHODS

We studied by echocardiography and carotid ultrasound 435 asymptomatic patients with metabolic syndrome. Patients with coronary artery disease or more than mild valvular heart disease were excluded. Carotid stiffness index (β) was measured using a high-resolution echo-tracking system. Patients with metabolic syndrome were divided into two groups: metabolic syndrome with three traits (Gr.1) and metabolic syndrome with four or five traits (Gr. 2).

RESULTS

Patients in Gr. 2 had higher left ventricular mass index (P < 0.001), left ventricular end-diastolic volume index (P = 0.029), left atrial volume index (P = 0.002), E/e' ratio (P = 0.002), intima-media thickness (P = 0.031), and prevalence of plaques (P = 0.01) than patients in Gr. 1. Left ventricular ejection fraction was similar in both groups. The mean carotid β index tended to be higher in Gr. 2. Considering metabolic syndrome traits separately, in an age-corrected multivariate analysis, abdominal obesity was found to have the strongest association with cardiac structure and carotid artery atherosclerosis and stiffness.

CONCLUSION

An increasing number of metabolic syndrome traits had a significantly worse impact on cardiac remodeling and function and carotid artery atherosclerosis. Abdominal obesity showed the strongest association with cardiac structure, carotid artery stiffness, and intima-media thickness. Prospective studies are needed to evaluate whether a new classification of metabolic syndrome using the number of traits could add prognostic information.

Left ventricular shape and mass impact torsional dynamics in asymptomatic patients with chronic aortic regurgitation and normal left ventricular ejection fraction

Chronic aortic regurgitation (AR) is associated with a unique pattern of left ventricular (LV) volume and pressure overload, leading to LV remodelling. LV torsional motion, a key component of LV performance, can be altered in this setting. We aimed to assess the impact of LV remodelling on LV torsional dynamics parameters using speckle-tracking echocardiography (STE) in asymptomatic AR patients. We prospectively enrolled 60 patients with chronic AR and LVEF > 50% and 55 healthy controls. LV rotation, twisting and untwisting were assessed using STE. Patients with AR had higher LV diameters, volumes and mass, a more spherical LV shape than controls, but similar LVEF. In AR patients we found reduced peak LV apical rotation and decreased (2.1 ± 0.8 vs 2.9 ± 0.9°/cm, p < 0.001) and delayed (time to peak LV twist: 0.94 ± 0.12 vs 0.99 ± 0.09, p = 0.004) peak LV torsion. Also, peak LV untwisting velocity was decreased (-123.5 ± 41.5 vs -152.3 ± 55.0°/s, p = 0.002) due to lower peak LV apical diastolic rotation rate. LV shape influenced LV torsional dynamics, a more spherical LV displaying reduced peak LV apical rotation and diastolic rotation rate and decreased LV twist. A more hypertrophied LV had a lower peak LV torsion, peak LV apical diastolic rotation rate and peak LV untwisting velocity. LV apical rotation and torsion are decreased and LV twist is delayed in patients with chronic AR and normal LVEF, detecting early subclinical LV dysfunction before LVEF declines. Also, LV untwisting is reduced in these patients. LV remodelling impairs LV torsional dynamics parameters in this setting.

The left ventricle in aortic stenosis--imaging assessment and clinical implications

Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement.

This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.

Predictive factors for obtaining a correct therapeutic range using antivitamin K anticoagulants: a tertiary center experience of patient adherence to anticoagulant therapy

BACKGROUND

Patient adherence is an essential factor in obtaining efficient oral anticoagulation using vitamin K antagonists (VKAs), a situation with a narrow therapeutic window. Therefore, patient education and awareness are crucial for good management. Auditing the current situation would help to identify the magnitude of the problem and to build tailored education programs for these patients.

METHODS

This study included 68 hospitalized chronically anticoagulated patients (mean age 62.6±13.1 years; males, 46%) who responded to a 26-item questionnaire to assess their knowledge on VKA therapy management. Laboratory and clinical data were used to determine the international normalized ratio (INR) at admission, as well as to calculate CHA2DS2-VASC and HAS-BLED scores for patients with atrial fibrillation.

RESULTS

The majority of patients (62%) were receiving VKA for atrial fibrillation, the others for a mechanical prosthesis and previous thromboembolic disease or stroke. In the atrial fibrillation group, the mean CHA2DS2-VASC score was 3.1±1.5, while the average HAS-BLED score was 1.8±1.2. More than half of the patients (53%) had an INR outside of the therapeutic range at admission, with the majority (43%) having a low INR. A correct INR value was predicted by education level (higher education) and the diagnostic indication (patients with mechanical prosthesis being best managed). Patients presenting with a therapeutic INR had a trend toward longer treatment duration than those outside the therapeutic range (62±72 months versus 36±35 months, respectively, P=0.06). There was no correlation between INR at admission and the patient's living conditions, INR monitoring frequency, and bleeding history.

CONCLUSION

In a tertiary cardiology center, more than half of patients receiving VKAs are admitted with an INR falling outside the therapeutic range, irrespective of the bleeding or embolic risk. Patients with a mechanical prosthesis and complex antithrombotic regimens appear to be the most careful with INR monitoring, especially if they have a higher level of education. Identifying patient groups with the lowest time interval spent in the therapeutic range could help attending physicians educate patients focusing on specific awareness issues.

Fabry disease--a primer for cardiologists

Fabry disease is an X-linked lysosomal storage disorder caused by α-galactosidase A deficiency. It is a systemic disease mostly affecting the kidneys, the heart and the brain. Cardiac involvement often presents as concentric nonobstructive left ventricular hypertrophy and is a differential to be taken into account by cardiologists. This review describes the most important systemic features, but mostly highlights the cardiac involvement. Patients with known Fabry disease should be screened early for cardiac involvement, as treatment benefit may not be seen once cardiac fibrosis has developed. Screening for Fabry can be effective among individuals with end-stage renal disease, unexplained cardiac hypertrophy or strokes in young people with no apparent predisposing factors. Enzyme replacement therapy reverses metabolic and various pathologic abnormalities and should be initiated in all patients with symptomatic Fabry disease.

Laparoscopic sleeve gastrectomy reduces the predicted coronary heart disease risk and the vascular age in obese subjects

BACKGROUND

Obesity is associated with high prevalence of coronary heart disease (CHD) and long term increased cardiovascular morbi-mortality. There are no data regarding the effect of laparoscopic sleeve gastrectomy (LSG) on long-term CHD - risk. It is known that "a man is as old as his arteries" and this concept is illustrated by Framingham coronary risk score, which can predict vascular age.

PURPOSE

To assess the 10-year CHD risk in patients with obesity, preoperatively, and 6 and 12 months after LSG.

METHODS

47 consecutive obese subjects (44.7% males, mean age 39.8 years) scheduled for LSG were prospectively studied before and 6 and 12 months after surgery. The 10 years CHD risk and corresponding vascular age were calculated using Framingham risk score.

RESULTS

The body mass index (BMI) decreased from 44.6 ± 10.6 kg m2 preoperatively to 32.2 ± 6.9 kg m2 and to 29.4 ± 5.4 kg m2 at 6 and 12 months follow-up (both p 0.05). Mean excessive weight loss (EWL) was 67.3 ± 23.7% and 78.3 ± 23.4% at 6 and 12 months postoperatively. At 6 and 12 months after LSG, there was a marked improvment of lipid profile(decrease of total cholesterol, LDL-cholesterol, triglycerides and increase of HDL-cholesterol) and a significant decrease in prevalence of diabetes mellitus, systemic hypertension and smoking. The 10-year CHD risk reduced from 10.1% preoperatively to 3.5% and to 2.2% at 6 and 12 months after surgery (both p 0.05). Patients' mean vascular age was 65.6 years preoperatively and decreased to 45.8 years 6 month spostoperatively (p 0.05) and to 40.7 years one year after LSG (p 0.05 vs. 6 months postoperatively, p=NS vs.chronological age).

CONCLUSIONS

In obese subjects, CHD risk is significantly reduced early, beginning with 6 months after LSG and is diminished with 80% one year postoperatively. Despite the fact that not all patients had achieved the ideal weight yet,mean vascular age is similar to their chronological age one year after surgery.

Fibromuscular dysplasia--a rare cause of renovascular hypertension. Case study and overview of the literature data

Renal artery stenosis (RAS) is associated with increased cardiovascular mortality and morbidity and may constitute a treatable cause of secondary hypertension. Fibromuscular dysplasia is frequently affecting children as the main cause of RAS, but is very rare in adults. We present the case of a 19-year-old overweight patient, with no known pathological conditions in her medical history or family background, admitted for severe, pulsing headaches during the past 3 months and increased blood pressure (BP) values for about a month (maximum BP 220/140 mmHg). The initial clinical exam and first-line imagistic methods did not provide a high suspicion for RAS. However, the invasive methods established the diagnosis of right renal artery medial dysplasia. Balloon angioplasty was the treatment of choice.

Morphological and Functional Adaptation of the Maternal Heart During Pregnancy

Background—

Pregnancy provides a unique model to study the adaptation of the heart in a physiological situation of transient load changes. The aim of this study was to assess the performance of the left ventricle (LV) in normal, uncomplicated pregnancies while considering the actual LV load and shape.

Methods and Results—

Serial echocardiographic examinations were performed in 51 women in each pregnancy trimester and 3 to 6 months after delivery. Data from 10 nulliparous, age-matched women were used as the control. Conventional parameters of LV function (ejection fraction) as well as myocardial deformation (strain) were interpreted, taking into consideration maternal hemodynamics and LV shape. Cardiac output increased during pregnancy because of a higher stroke volume in early pregnancy and a late increase in heart rate, whereas total vascular resistance decreased. Progressive development of eccentric hypertrophy was observed, which subsequently recovered postpartum. Sphericity index decreased from the first to the third trimester (1.92±0.17 versus 1.71±0.17) and returned postpartum to values comparable to the control. Although higher LV stroke work was noted toward the third trimester (5.9±1.1 versus 5.3±1.0 Newton meter, P <0.001), ejection fraction showed no significant changes. LV strain decreased significantly in late pregnancy (−19.5±2% to −17.6±1.6%, P <0.001) and returned to baseline values after delivery (−19.5±2%).

Conclusions—

Pregnancy is a physiological process associated with increased cardiac performance and progressive LV remodeling. These changes are not directly reflected by parameters traditionally considered to describe systolic function, such as ejection fraction and longitudinal deformation. While ejection fraction was insensitive to the functional changes, the transient decrease in longitudinal deformation becomes only plausible when considering the changes in LV geometry.

Structural and Functional Changes of Carotid Wall Properties in Patients with Acromegaly are not Restored after 1 year of GH/IGF1 Normalization

Vascular changes are common in acromegaly (ACM). Current therapies can normalise the levels of both growth hormone (GH) and insulin-like growth factor (IGF1).

To establish whether the ACM vascular changes in patients with effectively managed disease are different from those in patients with an active condition.

64 ACM patients were tested for serum GH (random and during an oral glucose tolerance test) and IGF1. Ultrasonography of the right common carotid (RCC) explored structural (the carotid diameter and intima-media thickness index (IMT)) and functional (the augmentation index (AIx), elastic modulus (Ep), and local pulse wave velocity (PWV)) arterial parameters in the ACM patients (groups A and B) and an age- and sex-matched control group of 21 patients without acromegaly (group C).

The ACM patients were divided into 2 subgroups that had similar cardiovascular risk factor profiles: A (n=10, with controlled ACM), and B (n=54, with active ACM). The AIx was higher in groups A (27.7% [2.2–54.3]) and B (20.0% [ − 38.2–97.1]) than in group C (3.5% [ − 11.3–31.1]), p=0.01 and 0.002, respectively. The group B patients presented with poorer functional carotid wall parameters than the control subjects: Ep-95.5 [33–280] KPa vs. 77.5 [39–146] KPa, p=0.01; and PWV-6 [3.6–10.4] m/s vs. 5.4 [3.9–7.2] m/s, p=0.03.

The ACM patients had greater RCC diameters (6.4±0.6 mm vs. 5.7±0.6 mm, p<0.001) and IMT values (0.72±0.13 mm vs. 0.58±0.08 mm, p<0.001) than the subjects in group C.

Both the controlled and active ACM patients showed structural arterial changes. After 1 year of disease control, the patients with controlled ACM showed improvements in the functional, but not the structural, arterial parameters compared with the patients with an active condition.

Aortic regurgitation due to quadricuspid aortic valve--case report and literature review

Quadricuspid aortic valve is a rare variant of aortic semilunar valve, often being an unexpected discovery during cardiac surgery. We present the case of a 59 years old patient, who was admitted for dyspnea on light exertion and palpitations. The transthoracic echocardiography revealed severe aortic valve regurgitation due to a quadricuspid aortic valve, the result being confirmed by the transesophageal echo examination. The patient had a first class indication for aortic valve replacement and the surgical intervention was uneventful. The operative technique and case particularities are discussed in view of the literature published so far regarding this uncommon condition.

Continuous murmur--the auscultatory expression of a variety of pathological conditions

Continuous murmur is a peculiarity of cardiovascular auscultation, relatively rare, which often hides complex cardiovascular diseases. This article is a review of literature data related to the continuous murmurs accompanied by commenting and illustrating them through our own cases.Recognizing of a continuous murmur and understanding the cardiovascular pathologies that it can hide, is a challenge in current practice.

Echo-tracking assessment of carotid artery stiffness in patients with aortic valve stenosis

BACKGROUND

There is little information about mechanical properties of large arteries in patients (pts) with aortic stenosis (AS).

METHODS

Nineteen patients with AS (aortic valve area: 0.88 +/- 0.29 cm(2)) and 24 control subjects without AS but with a similar distribution of risk factors were recruited. beta index, pressure-strain elastic modulus (Ep), arterial compliance (AC), augmentation index (AIx), and local pulse-wave velocity (PWV) were obtained at the level of right common carotid artery (CCA) by a real time echo-tracking system. Time to dominant peak of carotid diameter change waveform, corrected for heart rate (tDPc), and maximum rate of rise of carotid diameter (dD/dt) were measured. Systemic arterial compliance (SAC) was also calculated. Parameters of AS severity (mean gradient, valve area, stroke work loss [SWL]) were determined.

RESULTS

tDPc was higher in patients with AS than in controls (7.9 +/- 0.6 vs. 6.6 +/- 0.7, P < 0.0001) while dD/dt was lower (5.3 +/- 3.6 mm/s vs. 7.8 +/- 2.8 mm/s, P = 0.01). AIx was significantly higher in AS group (32.5 +/- 13.6% vs. 20.6 +/- 12.2%, P = 0.005) and had a linear correlation both with tDPc (r = 0.63, P < 0.0001) and with dD/dt (r =-0.38, P = 0.01). There was a significant correlation between carotid AC and SAC (r = 0.49, P = 0.03), but only carotid AC was related to SWL (r = 0.51, P = 0.02), while SAC was not (P = 0.26).

CONCLUSIONS

AIx was the only parameter of arterial rigidity found to be higher in patients with AS than in controls. Carotid AC showed a significant correlation with SAC and it seemed to be more closely related to AS severity than to SAC.

Restrictive cardiomyopathy--an outdated concept?

Restrictive cardiomyopathy is probably the least common of all cardiomyopathies, with a nonspecific clinical presentation and a frequently unknown cause. The concept of RCM has changed tremendously over time. Today it includes a large panel of disorders characterized by a non-hypertrophied, non-dilated cardiac phenotype and a restrictive ventricular filling pattern. Several unsuccessful attempts to define and classify cardiomyopathies have been made, but they all proved problematic due to the contradiction in terms and the overlap between classical patterns. Advances in disease pathology, genomics and molecular biology are emerging as the framework of a new revolutionary classification system, focused on the dynamic interaction between genotype and phenotype. In this context, RCM is evolving as a self-contained hemodynamic and pathophysiological concept, although questionable due to its uncertain practical utility.

Echocardiographic Assessment of Diastolic Heart Failure

A normal ejection fraction (EF) is present in >50% of patients with clinical features of heart failure (HF). This entity has been referred to as HF with normal EF (HFNEF), or diastolic HF. The underlying pathophysiology of HFNEF is still under debate and this is reflected in the unsatisfactory results of pharmacological treatment and in the high mortality and morbidity rates, which are similar to those for systolic HF. By providing evidence of left ventricular (LV) diastolic dysfunction in patients with clinical features of HF and normal LVEF, echocardiography, the most practical and widely available diagnostic modality, can offer two of the three current diagnostic criteria for HFNEF. Moreover, abnormalities in LV myocardial deformation and torsional dynamics at rest and during exercise were recently demonstrated in HFNEF patients by echocardiography. Newer echocardiographic parameters may improve the understanding of this complex entity, but further studies are needed before using them in clinical practice for the diagnostic and therapeutic approach of patients with HFNEF. This article discusses the current echocardiographic approach to the diagnosis of diastolic HF, as well as the potential role of newer echo indices and modalities.

Changes in plasma levels of MMP-9, MMP-7 and their inhibitors in patients with coronary artery disease

To describe the enzymatic profile of plasma matrix metalloproteinases (MMP-7 and -9) and tissue inhibitors of metalloproteinases (TIMP-1 and -2) in different categories of patients (pts.) with coronary artery disease (CAD), and their relationship with clinical status, left ventricular (LV) function and remodelling.

METHODS

Total plasma MMP7, active fraction of MMP9, TIMP1 and TIMP2 were determined in 68 consecutive pts with confirmed CAD (Group A, 56.6 +/- 9 y, 75% men, LVEF 56.4 +/- 11%) and compared with a control group of 23 pts. without cardiovascular disease and normal coronary arteries (Group B, 58.1 +/- 10 y, 56.5% men, LVEF 58.7 +/- 5%). LVEF and wall motion index (WMI) were computed. Diastolic function parameters were evaluated: mitral E/A ratio, E/E'septal ratio. We calculated global longitudinal (L), circumferential (C) and radial (R) strain (S) and strain rate (SR) values as the average of segmental values, by 2D strain analysis.

RESULTS

The active form of MMP9 differed significantly between group A and B, as did the MMP9/TIMP1 and MMP9/TIMP2 ratios (8.78 +/- 10.0 ng/ml vs 3.33 +/- 4.0 ng/ml; 5.43 +/- 3.4 vs 0.85 +/- 0.9, and 11.60 +/- 5.2 vs 3.71 +/- 1.0, respectively, p < 0.04 for all). Group A included 35 pts. with acute coronary syndromes (ACS) and 33 pts. with stable angina (SA), with similar profile of LVEF and number of coronary arteries involved. There were no significant differences in plasma MMP9, MMP9/TIMP1 and MMP/TIMP2 ratio between normal and SA group, but only between normal and ACS group (p = 0.02 for MMP9). In group A, only MMP7, TIMP1/MMP7 and TIMP2/MMP7 ratio correlated with markers of systolic function: LVEF, WMI and global LS.

CONCLUSION

There were no significant changes in extracellular matrix markers in pts. with chronic stable ischemia vs normals. Only active form of MMP9 and its ratio with TIMP differed significantly in ACS. Total MMP7 and its ratio with TIMP correlated with parameters of LV systolic function even in pts. with normal LVEF.

Mesenteric ischemia--a complex disease requiring an interdisciplinary approach. A review of the current literature

Mesenteric ischemia is caused by a reduction in intestinal blood flow with potential catastrophic clinical consequences: sepsis, bowel infarction, and death. In the recent years, the incidence of mesenteric ischemia increased, now accounting for 0.1% of hospital admissions. Among the multiple factors responsible for this change is the heightened awareness for the diagnoses, the advanced mean age of the population and the increasing number of critically ill patients. Acute mesenteric ischemia is a potentially fatal vascular emergency, with overall mortality of 60-80%; prompt diagnosis and treatment are paramount. A high index of suspicion in the setting of a compatible history and physical examination serves as the cornerstone to early diagnosis of mesenteric ischemia. Restoration of intestinal blood flow, as rapidly as possible, is the main goal of treatment in patients with acute mesenteric ischemia. This may be achieved by medical means, endovascular procedures and by surgery. Chronic mesenteric ischemia is an uncommon process that occurs only when severe atherosclerotic narrowing of a major splanchnic vessel exists in association with occlusion of one or two of the remaining vessels. Its diagnosis is mainly based on the characteristic clinical picture, on the presence of an occlusive lesion in the splanchnic vessels and on the absence of other common causes of abdominal pain. The means available for mesenteric revascularization are the surgical techniques of flow restoration and the more recently developed percutaneous transluminal procedures.

Echocardiography in congenital mitral valve regurgitation--the liaison between cardiologist and surgeon

Congenital heart diseases are broadly defined as those cardiac anomalies that are present at birth. By their very nature, such defects have their origin in embryonic development. Congenital mitral valve regurgitation is a rare disease occurring in infancy or childhood. In up to 60% of cases, congenital anomalies of the mitral valve occur in association with other cardiac lesions, and often more than one component of the mitral apparatus is involved. The true incidence of congenital mitral valve regurgitation (MVR) is difficult to determine accurately (0.21-0.42% from total mitral valve regurgitations); isolated congenital mitral regurgitation is uncommon. The Carpentier classification of congenital mitral valve disease is the most commonly used nomenclature based on a functional analysis of the mitral valve leaflet. The contemporary anatomic classification has the advantage of minimizing observer variability in the diagnosis and it offers a much better liaison between the cardiologist and surgeon.

Doppler flow patterns in the evaluation of pulmonary hypertension

Pulmonary arterial hypertension is defined as a group of diseases characterised by a progressive increase in pulmonary vascular load, leading to marked increase in pulmonary artery pressure, right ventricular failure and premature death. Given the nonspecific nature of its early symptoms and signs, pulmonary arterial hypertension (PAH) is often diagnosed in its advanced stages. Although clinical assessment is essential when initially evaluating patients with suspected PAH, echocardiography is a key screening tool in the diagnostic algorithm, because, in comparison with invasive measurements, it has the advantages of being safe, portable, and repeatable. Therefore, Doppler echo is the modality most frequently used in pulmonary hypertension patients. Several echocardiographic techniques centered on the Doppler principle (both conventional Doppler parameters and tissue Doppler imaging) used in the assessment of PAH magnitude and its cardiac effects are presented in this paper. They provide important data on the severity, possible causes and consequences of pulmonary hypertension, both initially and during follow-up, therefore having the ability to estimate disease progression, prognosis, or to monitor therapeutic response. Doppler echocardiography allows to noninvasively estimate systolic pulmonary arterial pressure (SPAP), mean and end-diastolic pulmonary arterial pressure, as well as the quantification of right ventricular (RV) function and the evaluation of pulmonary vascular resistance (PVR).

Cardiac involvement in myasthenia gravis--is there a specific pattern?

Myasthenia gravis is an autoimmune neuromuscular disorder characterized by skeletal muscle involvement, causing muscle weakness and fatigue. The prevalence of the disease is approximately 1:7500 with a maximal prevalence during the second and third decade in women and the fifth and sixth decade in men, although it may appear at any age. The disease has a slight female preponderance, with a sex ratio of 3:2. Cardiac involvement in myasthenia gravis may take several forms, ranging from asymptomatic ECG changes to ventricular tachycardia, myocarditis, conduction disorders, heart failure and sudden death. We hereby report two cases of patients with myasthenia gravis who developed signs and symptoms of cardiovascular involvement, requiring admission in a cardiology ward for further investigation and treatment. The particular characteristics of the first case may be summarized by the symptomatic conduction disturbances with frequent episodes of syncope in a patient with myasthenia gravis who necessitated permanent pacing and the difficulties we encountered in the establishment of conduction disturbancies etiology (due to the disease or due to the treatment with acetylcolinesterase inhibitors). The second case shows a different kind of cardiac involvement in myasthenia gravis--the ECG changes (giant diffuse T waves in a patient with cardiovascular risk factors) which needed further investigation and long term surveillance.

Risk profile in women with acute myocardial infarction

The studies in the literature of the past years have noticed the particular characteristics of the ischemic heart disease in women, who seem to be lacking early diagnosis and invasive treatment of coronary heart disease. They especially emphasize that the evolution, complications and mortality in myocardial infarction in women are more severe.

THE GOAL OF THE STUDY

The evaluation of clinical, investigational and therapeutic aspects in a lot of women with acute myocardial infarction (AMI) versus a lot of men with the same pathology, hospitalised in the same period.

MATERIAL AND METHODS

78 women hospitalised in the Emergency Institute of Cardiovascular Diseases between 1st January 1999 and 30th October 2001 with acute myocardial infarction. 109 men hospitalised in the Emergency Institute of Cardiovascular Diseases with acute myocardial infarction in the same period.

INCLUSION CRITERIA

acute myocardial infarction, coronary angiography +/=left ventriculography. The lot of study and the witness lot were divided into 3 subgroups based on the severity of coronary lesions: Group I: left main stenoses, Group II: stenoses >60% on the other epicardial coronary vessels, Group III: stenoses <60% on the other epicardial coronary vessels. The risk factors, clinical data, cardiac performance indices and medical and invasive treatment were compared between the two groups.

RESULTS/CONCLUSIONS

The women hospitalised with AMI were older than men, had more diabetes and hypertension as main risk factors than men, with the exception of smoking, had more frequent heart failure and diastolic dysfunction of left ventricle. The favorite invasive treatment in women was the angioplasty with application of stent and in men--coronary bypass.

Calcific aortic valve disease and aortic atherosclerosis--two faces of the same disease?

Calcific (degenerative) aortic valve disease is the most common etiology of acquired aortic valve stenosis. Historically, it was seen as a degenerative, "senile-like" process, resulting from aging--"wearing and tearing"--of the aortic valve. However, several lines of evidence suggest that calcific valve disease is not simply due to age-related degeneration but, rather, it is an active disease process with identifiable initiating factors, clinical and genetic risk factors, and cellular and molecular pathways that mediate disease progression. Histopathologically, the early lesions of aortic valve sclerosis resemble arterial atherosclerotic plaques. Furthermore, atherosclerotic risk factors and clinical atherosclerotic cardiovascular disease are independently associated with aortic sclerosis suggesting that it represents an atherosclerosis-like process involving the aortic valve. Until now, the only established treatment for symptomatic aortic valve stenosis has been valve replacement. Newer therapies that may modify or reduce the likelihood of developing aortic valve disease are highly desirable and are currently under investigation. In this article we tried to review the available data on calcific aortic valve disease, starting from histological and pathogenic aspects and finishing with therapeutic implications, in order to characterize its relationship with the atherosclerotic process.

[New approaches in coronary microcirculation]

The last decades, coronary microcirculation has become a very important territory because of its role in coronary circulation physiology and pathophysiology. Only its implication in coronary artery disease was known at the beginning, but subsequently its role in many others diseases was shown. The nontraditional pathophysiological construct sustains that myocardial microcirculatory dysfunction is the primary event, and the atherosclerotic plaque rupture or erosion is the secondary event. In some instances, the coronary microvascular dysfunction may be an epiphenomena, an important marker of risk or even a cause, thus becoming therapeutic target.

["Needle-to-scalpel"--the benefit of urgent CABG in significant left main coronary artery stenosis]

Left main coronary artery (LMCA) stenosis is a relatively infrequent but important cause of symptomatic coronary artery disease. The diagnosis of left main coronary artery disease is made by coronary angiography. Coronary artery bypass grafting is the first-line therapy, the standard treatment for LMCA stenosis, which improves the likelihood of survival, while percutaneous coronary intervention (PCI) is emerging as a possible alternative to surgery. We present the case of a patient with history and symptoms of stable angina pectoris, especially associated with exercise, variable threshold, since four years, and who describes a worsening of symptoms in the last month; the angina had become more frequent, more prolonged and occurred at a lower threshold. At about 20 hours from getting admitted to our hospital, the patient had severe and prolonged rest angina, associated with important changes on ECG, which led to the indication of emergency coronary angiography. This investigation showed severe left main coronary artery stenosis and significant lesions in other important vessels (three-vessel disease), in a patient with normal left ventricular function. The recurrence and the intensity of prolonged angina of our patient have necessitated urgent myocardial revascularization surgery with quadruple coronary-artery bypass grafting. After surgery, the patient was asymptomatic and he was discharged 8 days after in a good clinical state.

CONCLUSIONS

The advantage of coronary artery bypass grafting performed as urgent surgery for the treatment of our patient with left main coronary artery stenosis and concomitant acute coronary syndrome, shortly after coronary angiography, was obvious, significantly improved the clinical outcome, without postoperative ischemic complications.

Cardiovascular risk in patients with peripheral vascular diseases

Peripheral arterial disease (PAD) is characterized by increased incidence and prevalence, both of which increasing with age (prevalence about 19% above 70 years versus 2.5% below 60 years); PAD is strongly dependent upon smoking and diabetes mellitus as cardiovascular risk factors. Patients suffering from peripheral arterial disease are patients at high cardiovascular risk, albeit symptomatic patients (intermittent claudication) or asymptomatic patients (added risk for cardiovascular events 4-5%/year); these risks increase in patients needing revascularization surgery (6%), mainly due to association of coronary or cerebro-vascular disease. A fair assessment of preoperative risks (risks depending on patient background, type of surgery, emergency status of surgical procedure) aids in the optimal management of such patient both at the time of performing the procedure and in the long-term patient management. This is why new parameters are required for assessing the risk and identifying a subgroup of patients at high-risk for acute cardiovascular events and for customizing the diagnostic and therapeutic algorithms for such patients.

Compound heterozygosity for the C677T and A1298C mutations of the MTHFR gene in a case of hyperhomocysteinemia with recurrent deep thrombosis at young age

We report a case of a young woman with an extensive, recurrent deep vein thrombosis (DVT) diagnosed by CT scan and duplex ultrasound examination. All blood investigations for etiology of recurrent DVT were normal except for serum homocysteine level, which was mildly increased. No other thrombophilic factors could be found. The three main causes of hyperhomocysteinemia are genetic defects, nutritional deficiencies and insufficient elimination. In our case a genetic defect for one of the key enzymes of homocysteine metabolism was found to be the underlying cause. Oral anticoagulation and supplementation with pyridoxine, cyanocobalamine and folate was recommended. Whether therapy with B vitamins and folate can substantially reduce the recurrence of venous thromboembolic disease remains to be established.

The Coandă effect in cardiology

Many of the current technologies used today in clinical practice owe their lives to physicians. Coandă effect was originally described by the romanian scientist as a phenomenon with application in aerodynamics, the main field of interest for Henri Coandă. He made the observation that a thin liquid jet, passing through a narrow channel which is followed by a curved surface, deviates according to the surface' shape, adhering to it. The description of the phenomenon and a possible explanation was found in a patent registrated in France, in 1934. It is interesting how a physical phenomenon described 70 years ago has found its clear demonstration and real time visualization on color Doppler flow mapping. Coandă effect influences jet size and color encoding, determining (for eccentric jets) smaller color Doppler jet areas, greater variance and reverse velocity encoding. The phenomenon may alter the interpretation of color Doppler images and needs to be taken into account for an appropriate echocardiography assessment of valvular regurgitation and other abnormal flows.

Relationship Between Global Myocardial Index and Automatic Left Ventricular Border Detection Pattern to Identify Biventricular Pacing Candidates

OBJECTIVE OF THE STUDY

to evaluate the relation between global myocardial index (GMI) and the pattern of left ventricular (LV) volume curves variation, using automatic border detection (ABD), and their role in assessing LV asynchrony.

METHODS

We studied 52 patients (mean age = 55 +/- 17 years) with dilated cardiomyopathy. QRS duration (QRSd) and GMI were measured. Currently accepted TDI and M-mode parameters were used to indicate LV dyssynchrony. On-line continuous LV volume changes were recorded using ABD. Ejection time (ET ABD) was measured from the ABD wave-forms as time interval between maximal and minimal volume variation during LV electromechanical systole. We derived the ejection time index (ETiABD) as the ratio between ET ABD and RR interval (ETiABD = ET/RR).

RESULTS

31 patients had a QRSd > 120 ms and 21 patients had a QRSd < 120 ms. Ventricular dyssynchrony was observed in 39 patients (29 patients had a QRSd > 120 ms). GMI was significantly higher in patients with, than in patients without ventricular dyssynchrony (1.06 +/- 0.18 vs 0.73 +/- 0.13, P = 0.0001), while ETABD was significantly smaller (233 +/- 39 ms vs 321 +/- 28 ms, P = 0.0001). The corresponding difference for ETiABD was 26.9 +/- 6.8% vs 6.3 +/- 4%, P < 0.0001. By simple regression analysis an inverse linear correlation was observed between GMI and ETiABD (r(2) = -0.51, P < 0.0001). The pattern of ABD waveforms showed increased isovolumic contraction and relaxation times in patients with LV asynchrony, similar to the GMI pattern.

CONCLUSIONS

Regional delays in ventricular activation cause uncoordinated and prolonged ventricular contractions, with lengthening of the isovolumic contraction and relaxation times and shortening of the time available for filling and ejection. GMI explores these parameters and together with ABD might be useful to identify patients with ventricular asynchrony.

Cardiac tumors: the experience of a tertiary cardiology center

Cardiac tumors represent a rare condition, often presenting with severe symptoms and having a poor outcome in the absence of early diagnosis and therapy. The aim of this study was to assess the prevalence and type of cardiac tumors, the techniques used for the diagnosis and the therapy used in a tertiary cardiology center.

METHODS

During a 2-years period, among the 35004 patients (pts) hospitalized in our Cardiology Department, 24 pts were diagnosed with CTum (0.068% of all hospitalizations). A retrospective study of CTum cases was based on the patient files, with full clinical data, paraclinic investigations and therapy details.

RESULTS

In the CTum group (49 +/- 16.2 years, similar between men and women), the main symptoms leading to patients referral were dyspnea (15 pts, 62.5%) and embolic events (coronary, cerebral, peripheral arteries: 7 pts, 29%), while in 4 asymptomatic pts the diagnosis was incidental. Transthoracic echocardiography (TTE) detected the presence of CTum in all cases. In 20 pts (83%), TTE and transesophageal echocardiography (TEE) provided all the data required for preoperative assessment (tumor size, extension, location, insertion site). In 4 pts, additional CT and MRI investigations were necessary, mainly for complex disease (malignant secondary CTum). The imaging techniques suggested a diagnosis of benign tumor in 15 pts (62.5%) and malignant tumor in 5 pts. In 4 pts the tumor type could not be established. Myxoma was the most frequent diagnosis (14 pts, 58% CTum). Among malignant CTum, secondary tumors (melanoma, lung and uterine cancer) were more frequent than primary CTum (4 vs 1 pt). The localization of CTum was intracavitary in 22 pts, 91% mainly in the left atrium (15 pts), intramyocardic in 1 pt and pericardic in 1 pt. Surgery was performed in 18 pts, confirming the preoperative diagnosis in 17 cases (94%). In one case, a myxochondrosarcoma was diagnosed at pathology in a patient with an echocardiography-based preoperative diagnosis of myxoma.

CONCLUSIONS

CTum represent a rare condition, accounting for only 0.068% of hospitalizations in a tertiary cardiology center, but with severe clinical presentation. Echocardiography (TTE and TEE) is the essential imaging modality, allowing in most cases the diagnosis, classification and localization of CTum and their insertion site. CT and MRI are useful additional modalities in complex cases (mainly malignant primary and secondary CTum). In the case of benign tumors, surgery must be performed as soon as possible after the diagnosis has been established, whereas for malignant tumors there is still much controversy in what regards the benefits of surgery.

Understanding the genetic causes of inter-patient variability. Clinical relevance with focus on cardiovascular drugs

There is a large inter-patient variability concerning the response to drug therapy and a great interest for determining the causes of this variability. This review takes into discussion some aspects of cardiovascular drugs metabolism and transport, pointing out the effects of genetic variation. Isoenyzmes belonging to the Cytochrome P450 super family have an important role in cardiovascular drug metabolism, namely CYP 1A2; CYP 3A; CYP 2C19; CYP2C9; CYP 2D6, involved in the oxidative phase and also N-acetyltransferase 2, involved in the conjungative phase of the metabolism. P-glycoprotein is implied in cardiovascular drug transport. Polymorphisms of those enzymes and transport protein result in different phenotypes, that is the case of CYP isoenyzmes with abolished, low or increased activity and in the case of N-acetyltransferase 2, slow, intermediate and rapid acetylator phenotypes. There is hope that, in the future, a more individualized treatment of a certain disease, with minimum adverse effects and a maximum therapeutic effect, will be available, by means of genetic testing.

Current challenges of anticoagulant treatment

Anticoagulant therapy plays an important role in current medical practice. The main types of anticoagulant agents are: heparins, hirudins and vitamin K antagonists. None of the drugs used as anticoagulants meet the criteria of an ideal anticoagulant because they have side effects and they interact with other compounds. The main side effect of anticoagulant therapy is bleeding. The choice of a certain anticoagulant is made by the doctor based on the clinical context and also on the desired effect.

Myocardial infarction in young patients

Myocardial infarction (MI) is relatively rare in young patients. Atherosclerosis is responsible for most cases, but in one fifth of reported events other causes of MI are involved. Regarding individual susceptibility, it seems that cigarette smoking is the most common modifiable risk factor; family history and lipid abnormalities can also play an important role. In the absence of obvious risk factors a careful search for other contributing factors (such as vasospasm, vasculitis, cardiac masses or hypercoagulable states) is warranted.

Is acute myocardial infarction a localized or rather a global coronary phenomenon?

BACKGROUND

Use of qualitative assessment of coronary artery flow (TIMI), although widely spread, represents a subjective method, a quantitative assessment (CTFC) being necessary in order to standardize and facilitate comparisons and communications of angiographic trials. This study aims at appreciating whether myocardial infarction represents a global phenomenon that affects the whole myocardium, also affecting the coronary artery flow in non-culprit arteries.

MATERIALS AND METHODS

66 patients that underwent primary PCI with stent and 66 patients with normal angiographic coronary arteries were studied. The number of frames necessary for the dye to reach certain standardized landmarks was registered, in order to objectively assess the coronary artery flow as a continuous variable. The statistical evaluations revealed that the quantitative assessment of the coronary flow through CTFC (corrected TIMI frame count) pins up a difference between the flow on non-culprit coronary arteries (23.54+/-9.235) and the flow on normal angiographic coronary arteries (17.46+/-4.1) (p<0.005), the result being also valid for each of the three coronary arteries separately analyzed: LAD (23.88+/-8.08 vs. 18.575+/-4.59 - p<0.005), CX (20.7+/-7.34 vs. 15.62+/-3.35 - p<0.005) and RCA (26.45+/-11.91 vs. 18.2+/-3.69 - p<0.005).

CONCLUSIONS

There are significant differences regarding the flow on non-culprit coronary arteries in patients that suffered acute myocardial infarction (AMI) and the flow on the coronary arteries of the patients with normal angiographic results; these data might be the expression of global myocardial suffering.

Therapeutical perspectives for apoptosis modulation in cardiovascular disease

Apoptosis, or programmed cell death, is an active form of cell death, distinct from necrosis, through which multicellular organisms dispose of cells efficiently. Implication of apoptosis in the initiation and progression of many cardiovascular diseases, such as heart failure, systemic hypertension, coronary artery disease, has raised the possibility to elaborate new classes of medication to modulate this process. We review the most important drugs used in cardiovascular diseases and their interference with apoptosis, demonstrated by clinical studies as well as the involved mechanisms. We also analyze new molecules which protect cells from apoptosis and may therefore be clinically useful, as a new class of medication.

Congenital short QT syndrome. A review

Sudden cardiac death in individuals with structurally normal hearts accounts for approximately 20% of sudden cardiac death cases. Patients in this subgroup suffer from what has been named "electrical diseases" which are gradually coming into focus as inherited ion channelopathies, diseases of anchoring proteins or of intracellular calcium regulating proteins. From 1993, the Short QT Syndrome (SQTS) came to our attention, as a new inherited "electrical disease" associated with increased risk of sudden cardiac death and atrial fibrillation. Mutations of Ikr, Iks, Ikl channels cause dysfunctional Iks, Ikr, Ikl channels with an increase in the net outward K current leading to shortening of repolarization. This in turn leads to a shorter QT interval on the ECG and shorter atrial and ventricular refractory periods with increased susceptibility to VF and AF. There seems to be an autosomal dominant mode of inheritance. The clinical profile of SQTS consists of: family history of sudden cardiac death, personal history of palpitations, syncope, dizziness, resuscitated SCD, history of AF and documented VF. It is important to emphasize that SQTS is symptomatic from early age (new-born) to old age. Therefore, it is possible that SQTS accounts for some of the sudden infant death syndrome cases and for some cases of AF, especially lone AF. The only efficient treatment for ventricular arrhythmias is ICD, associated with drugs (Quinidine or Propaphenone) for AF prophylaxis and for reducing the number of ventricular arrhythmic events (and ICD discharges).

Is interleukin-18 correlated with endothelial dysfunction and platelet activation in patients with unstable angina?

The aim of the study was to assess the interaction between interleukin-18 (IL-18, a cytokine with a central role in the inflammatory cascade) and the presence of endothelial dysfunction and prothrombotic profile in patients with unstable angina and proven coronary artery disease.

MATERIAL AND METHODS

The study EDIT-ACS (Endothelial Dysfunction, Inflammation and Thrombosis in Acute Coronary Syndromes) was set in the Cardiology Department of our Institute, and inclusions were performed between June-November 2004. We included 40 consecutive patients with unstable angina hospitalized in our Department (mean age = 60.2 +/- 8.8 years, 57.5% male), as well as 20 normal pts as a control population,matched for age and sex (mean age = 61.9 +/- 8.6 years, 58.3% male). All pts had the following biological studies performed: interleukin-18 (IL-18), C-reactive protein (CRP), fibrinogen, leukocyte count, and Von Willebrand factor, as well as platelet activity parameters (mean platelet volume, MPV and platelet distribution width, PDW). All pts had echographic studies of flow mediated dilatation (FMD) and measurement of carotid intima-media thickness (C-IMT), and underwent coronary angiography as well.

RESULTS

We found that patients in the highest quartile of IL-18 had higher levels of CRP (11.9 +/- 4.2 vs 6.8 +/- 3.4 mg/l, p<0.01), von Willebrand factor (166% vs 150%, p=0.08), PDW (14.5 vs 13.2, p=0.04), MPV (11.2 vs 10.2, p=0.02), as well as a higher number of coronary stenoses (mean no. of affected vessels 2.5 vs 1.1, p<0.001), trend towards higher carotid IMT (0.92 mm vs 0.81 mm, p=0.06). They also have significant endothelial dysfunction (FMD of 5 % vs 8.5% for 4th quartile and 1st quartile respectively). Pts with higher levels of IL-18 associated a worse short term (in hospital prognosis) with 60% of pts in the 4th quartile having adverse events, versus 22% in the lowest quartile.

CONCLUSIONS

High levels of interkleukin-18 are associated with endothelial dysfunction (high von Willebrand factor and low brachial FMD) and platelet activation (high MPV and PDW values), in pts with a higher number of affected coronary arteries but similar global atherosclerotic burden. This could explain the association between high levels of IL-18 and worse short-term prognosis in pts with unstable angina.

The tachyarrhythmic cardiomyopathy--a rare entity in childhood

Persistent disturbances of rhythm with high heart rate may lead to reversible depression of left ventricular function and biventricular failure. This phenomenon may appear also in children with incessant supraventricular tachycardia. Because in most cases these patients are long time asymptomatic the diagnosis of these arrhythmias is very difficult and frequently is belated. In case of correct treatment of the arrhythmia, the cardiac function improves rapidly.

OBJECTIVE

To present a number of cases of incessant supraventricular tachycardia in children, which has led to tachyarrhythmic cardiomyopathy and heart failure.

MATERIAL AND METHOD

A number of six patients (pts.), aged between 3 years 10 m - 16 y, hospitalized between January 1st, 2001 - January 1st , 2004 were taken in study. All patients had long crisis of supraventricular tachycardia with incessant character. A clinical exam, an ECG, a chest X-ray film and an echocardiography were made to all patients. An electrophysiologic study was made in two cases. The emergency therapy was the drug therapy.

RESULTS

At the moment of hospitalization all patients had a depression of the contractile function of the myocardium. After the control of the arrhythmia the ejection fraction recovered in a period between 3 months and one year.

CONCLUSION

The disturbances of rhythm may induce a depression of the contractile function of the myocardium, which is reversible in many cases. The correct antiarrhythmic treatment led to the improvement of the heart failure in this case.