278 Cardiac involvement in a 23 years old patient with granulomatosis with polyangiitis (GPA)

Aims

Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis, which could potentially affect any organ system. However, there have only been a few reports on cardiac involvement. In fact, it most commonly involves the sinuses, lungs, and kidneys with necrotizing granulomatous vasculitis. In 12% of a large series of patients with GPA there was cardiac involvement, largely manifested by pericarditis and coronary arteritis.

Methods and results

We describe a rare case of a 23-year-old girl, with no pathological history, at exception of a recent flu-like syndrome for which she carried out the search for SARS-CoV-2 RNA through nasopharyngeal swab, results negative. After a month, she went to the emergency department for a syncopal episode and subsequent head trauma. On this occasion, echocardiogram performed showed the presence of left ventricular systolic dysfunction due to hypokinesia of the middle distal segments; CT angiography of the chest revealed the presence of pulmonary embolism. For this reason, the patient was admitted to the cardiac intensive care unit, where EKG shown anterolateral myocardial infarction with ST elevation and immediately was performed coronary angiography, that evidenced two-vessel disease, with subsequent ineffective attempt to angioplasty. Due to the intercurrent appearance of hyposthenia and paraesthesia in the left upper limb, CT angiography of the brain was performed with detection of lower right pre central frontal hypodensity, suspected for recent ischaemic lesion and hypodensity of the right carotid artery as recent thrombosis. In light of the multi-organ involvement of ischaemic nature and the young age of the patient, rheumatological evaluation was carried out, with execution of a laboratory tests that showed the presence of positivity for ANCA anti-PR3 antibodies, on the basis of which was diagnosed GPA, and rituximab therapy was immediately initiated, with clinical benefit.

Conclusions

Cardiac involvement of GPA was first reported by Wegener in 1936. Classical or generalized GPA is characterized by necrotizing granulomatous vasculitis of the upper and lower respiratory tract together with glomerulonephritis. Widespread disseminated vasculitis involving both small arteries and veins occurs to a greater or lesser degree as the disease progresses. A localized form of GPA limited primarily to the upper and lower respiratory tracts has been described. Despite histopathological diagnosis of GPA, with autoantibodies against to circulatory neutrophilic cytoplasmic antigens, we can diagnose GPA easily and early. GPA must be kept in mind as the differential diagnosis of new onset cardiomyopathy, especially in the existence of pulmonary and renal pathologies. The clinical presentation of GPA can be so diverse that the list of differential diagnoses is vast, ranging from infections (fungal, bacterial, and mycobacterial) to other vasculitides, including Henoch–Schönlein purpura, sarcoidosis, Behcet syndrome, and malignancies. Despite that involving the heart is well described, significant cardiac complications occurring during the course of the disease are rare.

261 A case of metastatic myxoid liposarcoma causing cardiac tamponade

Aims

Primary cardiac tumors are generally benign. In one series of over 12 000 autopsies, only seven cases of malignant primary cardiac tumors were identified, for an incidence of less than 0.1%. By comparison, metastatic involvement of the heart is over 20 times more common and has been reported in autopsy series in up to one in five patients dying of cancer. Myxoid liposarcoma (MLS) is the second most common subtype of liposarcoma and it usually occurs in deep tissues of the extremity, especially in the calf or thigh. Some tumors have round cell areas that represent histologic progression to high-grade tumours. Round cells, defined as > 5% of the total cells, are associated with higher malignancy and metastatic potential, resulting in an unfavourable outcome in patients affected. Patients with MLS tend to have metastases to extra pulmonary sites, such as abdominal wall, abdominal cavity, retroperitoneum, and bone, even in the absence of pulmonary metastases. Although several authors have reported a high proportion of extra pulmonary metastases of MLS, cardiac metastasis is extremely rare.

Methods and results

We present a case of a young woman who underwent resection of calf liposarcoma with the onset of cardiac metastases after 18 years, with cardiac tamponade as a clinical onset. MRI confirmed the cardiac solid mass already evident on CT scan, located along the free anterior wall of the right ventricle in the mid-basal area; the lesion seemed to have pericardial implantation with the free wall of the right ventricle was not well cleaved by the lesion in the Cine-MRI sequences. However it was always visible in the post-contrast sequences without evident protrusion of the lesion into the cavity or signs of thrombosis. The parietal pericardium was located on the periphery of the lesion and was not recognizable in some points. The lesion consisted of two portions, a lower one in which some components with characteristics of adipose signal were recognizable, while the upper one was more solid and vascularized. There was persistence of inhomogeneous and diffuse late enhancement at the lesion level. PET revealed pathological hyper accumulations of radiopharmaceuticals in the heart lesion along the anterior wall of the right ventricle, with central hypocaptation area, possible expression of necrotic-colliquative phenomena. Other hyper accumulations were found in the mediastinal lymph node in the pre-carenal area. These findings were referable to the presence of glucose hyper metabolic tissue of suspected neoplastic significance. The patient temporarily declined surgical excision, but after one month, due to the worsening of her symptoms, she returned to emergency room: The CT scan showed a volumetric increase in cardiac mass with a vertical diameter of 8 cm and adhering to the right ventricle for 7 cm. Thanks to the possibility of surgery, patient underwent exeresis of the capsulated epicardial mass adhering to the anterior wall of the right ventricle and to the pericardium, with removal of the ventricular wall and reconstruction with a bovine pericardium patch and without postoperative complications.

Conclusions

In MLS the time intervals between the onset of primary disease and cardiac metastasis were reported to be relatively long, ranging from 1 to 25 years. The initial site of metastatic disease in our patient was the heart: she had a solitary cardiac tumour that presented 18 years after the primary surgery in the absence of metastases at other sites. When a cardiac metastasis is found incidentally, it is usually incurable.

COAPT-Like Profile Predicts Long-Term Outcomes in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation

OBJECTIVES

The aim of this study was to evaluate whether fulfilling COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) criteria identifies patients with better outcomes after MitraClip treatment for secondary mitral regurgitation (SMR).

BACKGROUND

To date, COAPT is the only trial showing a prognostic benefit of MitraClip implantation compared with conservative management.

METHODS

Three hundred four patients with SMR undergoing MitraClip placement in addition to optimal medical therapy at 3 European centers were analyzed. A COAPT-like profile was defined as absence of all the following criteria: severe left ventricular impairment, moderate to severe right ventricular dysfunction, severe tricuspid regurgitation, severe pulmonary hypertension, and hemodynamic instability. Freedom from all-cause death and from a composite endpoint (cardiovascular death and heart failure hospitalization) were evaluated at 2- and 5-year follow-up.

RESULTS

A COAPT-like profile was observed in 65% of the population. Compared with non-COAPT-like patients, those fulfilling COAPT criteria had greater survival free from all-cause death and from the composite endpoint at both 2 year (75% vs. 55% and 67% vs. 47%; p < 0.001 for both) and 5-year (49% vs. 25% and 40% vs. 19%; p < 0.001 for both) follow-up. Among the non-COAPT-like patients, similar outcomes were observed in those fulfilling 1 or ≥1 criterion. Left ventricular impairment had a late impact on outcomes, while right ventricular impairment, pulmonary hypertension, and hemodynamic instability had early effects. COAPT-like profile was an independent predictor of long-term outcomes, as well as administration of neurohormonal antagonists, European System for Cardiac Operative Risk Evaluation II score, and previous heart failure hospitalization.

CONCLUSIONS

A COAPT-like profile, including specific echocardiographic and clinical criteria, identifies patients with SMR who have a better prognosis after MitraClip implantation.

Left ventricular reverse remodelling predicts long-term outcomes in patients with functional mitral regurgitation undergoing MitraClip therapy: results from a multicentre registry

AIMS

To explore whether left ventricular reverse remodelling (LVRR) is a predictor of outcomes in patients with functional mitral regurgitation (FMR) undergoing MitraClip procedure.

METHODS AND RESULTS

We analysed 184 consecutive patients with FMR who underwent successful MitraClip procedure. LVRR was defined as a reduction in left ventricular end-systolic volume ≥ 10% from baseline to 6 months. LVRR was observed in 79 (42.9%) patients. Compared with non-LVRR, LVRR patients were more likely to be females, less likely to have an ischaemic aetiology of mitral regurgitation or a prior (<6 months) heart failure (HF) hospitalization, and had smaller left ventricular dimensions. New York Heart Association class improved from baseline up to 1-year follow-up in both groups. Higher rates of overall survival (87.3% vs. 75.2%, P = 0.039), freedom from HF hospitalization (77.2% vs. 60%, P = 0.020), and freedom from the composite endpoint (cardiovascular mortality or HF hospitalization) (74.7% vs. 55.2%; P = 0.012) were observed in LVRR vs. non-LVRR patients at 2-year follow-up. LVRR was associated with a significant reduction of the adjusted relative risk of mortality, HF hospitalization and composite endpoint [hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.20-0.96, P = 0.040; HR 0.55; 95% CI 0.32-0.97, P = 0.038; and HR 0.54; 95% CI 0.32-0.92, P = 0.023, respectively]. Female gender, absence of diabetes, freedom from prior HF hospitalization, non-ischaemic aetiology of mitral regurgitation, and left ventricular end-diastolic diameter < 75 mm were found to be independent predictors of LVRR.

CONCLUSIONS

Left ventricular reverse remodelling is associated with better long-term outcomes in patients with FMR successfully treated with MitraClip. A careful patient selection may be useful as specific baseline features predict favourable left ventricular remodelling. [Correction added on 17 January 2019, after online publication: the preceding sentence has been changed.].

Role of different vascular approaches on transcatheter aortic valve implantation outcome: a single-center study

OBJECTIVE

To compare different vascular approaches on clinical outcome of patients undergoing transcatheter aortic valve implantation (TAVI) with self-expandable bioprosthesis.

METHODS

We included all the patients undergoing CoreValve implantation at our institute between September 2007 and March 2014. They were divided into four groups based on the vascular approach: percutaneous transfemoral (pTF), cut-down transfemoral (cTF), transaxillary (TAx) and transaortic (TAo). Clinical outcomes were evaluated according to Valve Academic Research Consortium-2 recommendations.

RESULTS

Out of 322 consecutive patients, 170 (53%) underwent pTF, 76 (23%) cTF, 32 (10%) TAx and 44 (14%) TAo approach. Although the TAx and TAo patients had a higher risk profile, they had a similar outcome compared with the pTF and cTF groups; in particular, there were no differences regarding cardiovascular and all-cause mortality at 30 days, 1 and 2 years, as well as stroke, myocardial infarction, bleeding, major vascular complications, permanent pacemaker implantation and acute kidney injury rates. The observed device success rate was higher in the TAo than in the other approaches (88.6 versus 65.9, 68.7 and 76.3% in the pTF, cTF and TAx groups, respectively; P = 0.019). No differences occurred regarding 30-day early safety and 1-year clinical efficacy across the four groups. Fluoroscopy time, amount of contrast medium used and minor vascular complications were significantly higher in pTF patients, as well as in-hospital stay in the TAo group. Atrial fibrillation and prosthetic valve regurgitation, but not the vascular approach, were independent predictors of all-cause mortality.

CONCLUSION

A more invasive vascular approach, for CoreValve implantation, even in higher risk patients, does not affect early-term, mid-term and long-term outcomes.

The study of left ventricular diastolic function by Doppler echocardiography: the essential for the clinician

The study of diastolic function by Doppler-echocardiography is complex and demanding. The cardiologist/echocardiographist must have a systematic approach to the study of left ventricular diastolic function, not only based on the Doppler index, but integrating Doppler patterns with other echo-parameters (chamber dimensions, wall thicknesses, systolic function, valve function and morphology) and clinical information. A rational interpretation of clinical and instrumental data can allow a correct diagnosis, which is essential for clinical decision-making.

Chest Blunt Trauma: An Uncommon Cause of Aortic Stentless Bioprosthesis Dysfunction

Acute leaflet rupture occurred in a Freedom Solo (Sorin Group, Milan, Italy) pericardial stentless aortic bioprosthesis after chest blunt trauma 8 years after valve replacement. Intraoperative findings revealed an acute tear of the right cusp at the level of the structural suture line. Pericardial leaflets were not degenerated at histologic analysis. Reoperation was easy, with simple removal of the prosthetic cusps, and a sutureless Perceval (Sorin Group) bioprosthesis was successfully implanted. This is the first reported case of an acute rupture of a stentless aortic bioprosthesis after a chest blunt trauma and the first histologic analysis of an 8-year-old Freedom Solo.

Direct transcatheter aortic valve implantation with self-expandable bioprosthesis: feasibility and safety

BACKGROUND

Balloon valvuloplasty has been considered a mandatory step of the transcatheter aortic valve implantation (TAVI), although it is not without risk. The aim of this work was to evaluate the feasibility and safety of TAVI performed without pre-dilation (direct TAVI) of the stenosed aortic valve.

MATERIAL AND METHODS

Between June 2012 and June 2013, 55 consecutive TAVI performed without pre-dilation at our institution using the self-expandable CoreValve prosthesis (Medtronic, Minneapolis, MN) were analyzed and compared with 45 pre-dilated TAVI performed the previous year. Inclusion criteria were a symptomatic and severe aortic stenosis. Exclusion criteria were defined as presence of pure aortic regurgitation, degenerated surgical bioprosthesis or bicuspid aortic valve and prior procedure of balloon aortic valvuloplasty performed as a bridge to TAVI.

RESULTS

High-burden calcification in the device landing zone, assessed by CT scan, was found in most of the patients. The valve size implanted was similar in both groups. Device success was higher in direct TAVI (85%vs.64%,p=0.014), mostly driven by a significant lower incidence of paravalvular leak (PVL≥2;9%vs.33%,p=0.02). Safety combined end point at 30 days was similar in both groups.

CONCLUSION

Compared to TAVI with pre-dilation, direct TAVI is feasible regardless of the presence of bulky calcified aortic valve and the valve size implanted. Device success was higher in direct TAVI, mostly driven by a lower incidence of paravalvular leak. Safety at 30 days was similar in two groups.

[Percutaneous treatment of valvular heart diseases]

Surgical valve replacement represents the treatment of choice for symptomatic and severe valvular heart disease. However, the operative risk is increased in presence of advanced age and comorbidities, therefore such patients are often not deemed suitable for surgical treatment. Recently, percutaneous valve replacement has emerged as an optional treatment for such patients, particularly for treating severe aortic stenosis and severe mitral regurgitation.

Giant asymptomatic left atrial myxoma

The classic triad of myxoma clinical presentation is characterized by intracardiac obstruction, embolisms, and constitutional symptoms with fever, weight loss, or symptoms resembling connective tissue disease. Giant myxoma without symptoms are very rare. We present a case of a 30-year-old female with a giant asymptomatic myxoma in the left atrium, discovered by echocardiography. The patient was asymptomatic.

Genetic analyses of Trypanosoma cruzi isolates from naturally infected triatomines and humans in northeastern Brazil

Trypanosoma cruzi genetic diversity was investigated in 25 isolates (vectors and humans) from the semiarid zone of the State of Rio Grande do Norte, Brazil. Molecular markers (3' region of the 24Salpha rRNA; mitochondrial cytochrome oxidase subunit 2 (COII) gene; spliced leader intergenic region (SL-IR) gene; allelic size microsatellite polymorphism) identified 56% TcIII (100% Panstrongyluslutzi; 50% Triatomabrasiliensis); 40% TcII (91.7% humans; 50% T. brasiliensis) and 4% TcI (human). Microsatellite analysis revealed monoclonal and heterozygous patterns on one or more microsatellite loci in 64% of T. cruzi isolates (92.3% triatomines; 33.3% humans) and 36% putative polyclonal populations (66.7% humans; 7.7% triatomines) by loci SCLE10, SCLE11, TcTAT20, TcAAAT6, all belonging to TcII. Identical T. cruzi polyclonal profiles (88.9%) were detected, mostly from humans. The adaptative natural plasticity of TcII and TcIII and their potential for maintaining human infection in T. brasiliensis were confirmed. Intraspecific and phylogenetic T. cruzi diversity in the sylvatic and domestic transmission cycles in this specific region will provide exclusive control strategies.

Role of host lysosomal associated membrane protein (LAMP) in Trypanosoma cruzi invasion and intracellular development

Trypanosoma cruzi host cell entry depends on lysosomes for the formation of the parasitophorous vacuole. Lysosome internal surface is covered by two major proteins, highly sialilated, Lysosome Associated Membrane Proteins 1 and 2. T. cruzi, on the other hand, needs to acquire sialic acid from its host cell through the activity of trans-sialidase, an event that contributes to host cell invasion and later for parasite vacuole escape. Using LAMP1/2 knock out cells we were able to show that these two proteins are important for T. cruzi infection of host cells, both in entrance and intracellular development, conceivably by being the major source of sialic acid for T. cruzi.

Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome

AIMS/OBJECTIVES

This review examines the 'tako-tsubo-like' syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome.

METHODS

We have evaluated the data from literature for a comprehensive consideration of multiple aspects of this syndrome.

RESULTS/FINDINGS

Transient left ventricular apical ballooning typically affects women, and the clinical presentation is comparable to acute coronary syndrome with chest pain or sudden dyspnoea, changes in ECG and elevated cardiac enzymes in the absence of significant coronary stenosis, with complete resolution of wall-motion abnormalities in a period of days or weeks. This syndrome is triggered by marked psychological or physiological stress. Several pathophysiological mechanisms have been proposed, such as cathecolamine-mediated cardiotoxicity, abnormalities in coronary microvascular function and multivessel coronary vasospasm. The highest incidence of transient left ventricular apical ballooning is in the Japanese population, but it has been recently identified also in the USA and Europe. Treatment is empirical and supportive. The prognosis is generally favourable, although some deaths have been reported, usually the result of irreversible cardiogenic shock, refractory ventricular arrhythmias, or other catastrophic cardiovascular event.

CONCLUSIONS/INTERPRETATIONS

We conclude by emphasising the importance of a more deeper knowledge of this syndrome for general physicians and cardiologists and it should be often considered as a possible diagnosis occurring in emergency department and in patients admitted in the Chest Pain Units with a diagnosis of coronary acute syndrome.

Imaging of caseous calcification of the mitral annulus

Caseous calcification of the mitral annulus is a rare form of periannular calcification that generally appears as a calcified mass with a central echolucent area that may lead to diagnostic errors. The case is reported of a 65-year-old woman in whom a suspicious mass was detected with transthoracic echocardiography performed for dyspnea.

Measurement of the myocardial performance index in ambulatory patients with heart failure: correlation with other clinical and echocardiographic parameters and independent prognostic value

BACKGROUND

Many echocardiographic parameters have been proposed for the assessment of the patients with heart failure (HF). Recently, the myocardial performance index (MPI) has been shown to be an accurate index of myocardial function. We assessed the correlation with other clinical and echocardiographic measurements and the prognostic value of MPI in patients with HF.

METHODS AND RESULTS

The MPI was assessed in 112 consecutive patients with persistent symptoms of HF (II-III NYHA class), sinus rhythm, LV systolic dysfunction (defined by an ejection fraction <or= 45%). At multivariable analysis, only NYHA class and ejection fraction were independently related to MPI. The severity of mitral regurgitation and MPI were the only parameters independently related to the incidence of death or cardiovascular hospitalizations. A MPI > 0.55 (median value) and medium to severe mitral regurgitation were associated with a relative risk of cardiovascular events of 18.7 (95% confidence interval [CI], 16.6-20.7; P < 0.005) and of 3.03 (95% CI, 2-4.1; P = 0.035), respectively.

CONCLUSIONS

In our patients with HF, MPI was the best predictor of cardiovascular events. Mitral regurgitation was the only other variable which had an additive prognostic value at multivariate analysis.

A giant interatrial mass: an unusual presentation of primary amyloidosis

We report a patient with primary systemic amyloidosis who had a very unusual form of clinical and instrumental presentation.

A quadricuspid aortic valve associated with severe aortic regurgitation and left ventricular systolic dysfunction

We report a case of a quadricuspid aortic valve associated with severe aortic regurgitation and left ventricular systolic dysfunction.

[Usefulness of left atrial diametres and volumes for the evaluation of left ventricular diastolic function]

INTRODUCTION

The diastolic function of the left ventricle is a main point of the physiological adaptations of the cardiovascular system to the various situations.

AIM OF THE STUDY

Evaluation of left atrium diameter change during diastole and left atrial volume and their possible correlation with different left ventricular diastolic filling pattern.

MATERIAL AND METHODS

Ninety patients with echocardiographically determined diastolic dysfunction and eighty healthy volunteers were included in the study. We measured left atrium emptying fraction (LAEF), defined as ratio of end-diastolic left atrial diameter to end-systolic diameter and left atrial volume. Mitral flow pulsed wave velocities were recorded. E, A, E/A, deceleration time of early diastolic filling, isovolumetric relaxation time were measured. Pulmonary vein S, D and atrial reversal velocities and tissue Doppler imaging of E' and A' mitral anular velocities were obtained.

RESULTS

LAEF was found 0.6 +/- 0.4 (mean SE) in the control group, 0.81 +/- 0.04 in pseudonormal pattern (P < 0.05, control vs pseudonormal group), 0.89 +/- 0.01 in the greater A wave than E wave (P < 0.001, control vs restrictive pattern group), and 0.78 +/- 0.2 in the A > E group (P < 0.05, control vs A > E pattern group).

CONCLUSIONS

LAEF and atrial volume are a new and practical methods for the differentiation of the normal-pseudonormal mitral flow pattern, in particular in setting without new ultrasound technologies.

Thrombus or tumor? a case of fibroelastoma as indicated during the submission process

We describe the case of a 50-year-old woman who was admitted to a pheriferal department for heart failure. The echocardiography revealed a small mass measuring about 1.3 x 1.0 cm adhering to the non-coronary cusp of the aortic valve, mild dilated cardiomiopathy and severe biventricular dysfunction. This mass had erroneously been considered a thrombotic lesion, so the patient was treated with thrombolysis and heparin e.v. Only after a transoesophageal echocardiography a tumour cardiac mass was suspected. The diagnosis of fibroelastoma was confirmed by MRI and then from the anatomic and histoligical definition after surgery.

Acute thrombosis in mitralic mechanical prosthesis: a case report

We describe a case of a man, 42 years old, submitted to successful fibrinolitic strategy with rTPA in acute mitralic prosthesis valve thrombosis and ipomobility of one emidisk. There aren't a consensus agreement in therapeutic strategy but we may support the approach of some authors that employ fibrinolisis in patients without absolute or relative controindications and if thrombus dimension is less than 1 cm otherwise they make use of heparin therapy in non obstructive thrombosis with successive transesophageal echocardiography evaluation for the efficacy and the later indication for thrombolisis or surgery treatment.

CA 125 tumoral marker plasma levels relate to systolic and diastolic ventricular function and to the clinical status of patients with chronic heart failure

Plasma levels of the tumoral carbohydrate 125 antigen marker (CA 125) have been found elevated in patients with heart failure. We measured the plasma levels of CA 125 and other tumoral markers in a group of patients with chronic heart failure and we found a correlation between the serum levels with some left ventricular parameters calculated with transthoracic echocardiography (ETT). We studied 200 patients, 159 males and 41 females, suffering from idiopathic or ischemic cardiomyopathy, 126 of them in NYHA class II, 39 in class III, and 35 in NYHA class IV. CA 125 levels were correlated with Doppler mitral flow E-wave, E/A ratio, deceleration time (DT), isovolumetric relaxation time (IVRT), and myocardial performance index (MPI) (r = 0.38, 0.35, -0.46, -0.48, and 0.35, respectively, all with P < 0.05). Multiple regression analysis found the following parameters to be independently correlated to CA 125: long- and short-axis diameter, MPI, IVRT, and E/A. Plasma CA 125 levels were raised in patients with chronic heart failure and were related to clinical condition and to diastolic and systolic function parameters of the left ventricle. CA 125 could be used as an additional, noninvasive, easily determinable, and low-cost marker of the clinical condition of patients affected by heart failure.

Dynamic mild subaortic left ventricular obstruction caused by an accessory mitral valve attached to the anterior mitral valve in a young pregnant woman

Accessory mitral valve tissue is an extremely rare congenital cardiac anomaly of embryologic development of the endocardial cushion. This anomaly is often associated with left ventricular outflow tract obstruction (LVOTO). A 26-year-old pregnant female was referred to our Department of Cardiology with exertional shortness of breath and tachycardia. Transthoracic and transesophageal echocardiography revealed a flexible circular (1.3 x 1.4 cm), mobile structure attached to the ventricular side of anterior mitral valve leaflet, with chordal attachments structure from anterior papillary muscle. This picture is compatible with a parachute-like accessory mitral valve tissue. We performed an echocardiographic exercise test that shows a systolic flow turbulence starting immediately proximal to this structure, resulting in a small increase in left ventricular outflow tract (LVOT) gradient (30 mmHg). Therefore we started low dose of beta-blocker therapy in order to decrease heart frequency and reduce the future risk of a worsening of an LVOT dynamic obstruction. Transthoracic and transesophageal echocardiography is critical for the differential diagnosis of LVOT and in the management of accessory mitral valve tissue. In patients without rest and only an exertional mild LVOTO and no other cardiac malformations, prophylactic removal of mitral accessory tissue excision is not required; antibiotic prophylaxis for endocarditis can be indicated and a regular follow-up is recommended to identify any progression in LVOTO entity.

Coronary artery fistula: diagnostic role of transthoracic and transesophageal echocardiography

Congenital coronary artery fistulas (CAFs) are rare. Some patients develop symptoms of congestive heart failure secondary to a large left-to-right shunt or myocardial ischemia from coronary artery steal in the first few years after birth. After the second decade the frequency of symptoms and complications increase. We report a case of CAF originating from the circumflex artery and draining into the coronary sinus, associated with left main coronary aneurysm. Transtho-racic and transesophageal echocardiography approach showed the origin, course, and drainage site of the CAF. This case represents a typical sample of this rare anomaly and puts into evidence the essential role of echocardiography to define and complete the angiographic diagnosis.

Cell culture and animal infection with distinct Trypanosoma cruzi strains expressing red and green fluorescent proteins

Different strains of Trypanosoma cruzi were transfected with an expression vector that allows the integration of green fluorescent protein (GFP) and red fluorescent protein (RFP) genes into the beta-tubulin locus by homologous recombination. The sites of integration of the GFP and RFP markers were determined by pulse-field gel electrophoresis and Southern blot analyses. Cloned cell lines selected from transfected epimastigote populations maintained high levels of fluorescent protein expression even after 6 months of in vitro culture of epimastigotes in the absence of drug selection. Fluorescent trypomastigotes and amastigotes were observed within Vero cells in culture as well as in hearts and diaphragms of infected mice. The infectivity of the GFP- and RFP-expressing parasites in tissue culture cells was comparable to wild type populations. Furthermore, GFP- and RFP-expressing parasites were able to produce similar levels of parasitemia in mice compared with wild type parasites. Cell cultures infected simultaneously with two cloned cell lines from the same parasite strain, each one expressing a distinct fluorescent marker, showed that at least two different parasites are able to infect the same cell. Double-infected cells were also detected when GFP- and RFP-expressing parasites were derived from strains belonging to two distinct T. cruzi lineages. These results show the usefulness of parasites expressing GFP and RFP for the study of various aspects of T. cruzi infection including the mechanisms of cell invasion, genetic exchange among parasites and the differential tissue distribution in animal models of Chagas disease.

Ubiquitylated Tax targets and binds the IKK signalosome at the centrosome

Constitutive activation of the NF-kappaB pathway by the Tax oncoprotein plays a crucial role in the proliferation and transformation of HTLV-I infected T lymphocytes. We have previously shown that Tax ubiquitylation on C-terminal lysines is critical for binding of Tax to IkappaB kinase (IKK) and its subsequent activation. Here, we report that ubiquitylated Tax is not associated with active cytosolic IKK subunits, but binds endogenous IKK-alpha, -beta, -gamma, targeting them to the centrosome. K63-ubiquitylated Tax colocalizes at the centrosome with IKK-gamma, while K48-ubiquitylated Tax is stabilized upon proteasome inhibition. Altogether, these results support a model in which K63-ubiquitylated Tax activates IKK in a centrosome-associated signalosome, leading to the production of Tax-free active cytoplasmic IKK. These observations highlight an unsuspected link between Tax-induced IKK activation and the centrosome.

Coronary-to-bronchial anastomosis: an unusual cause of hemoptysis

Coronary-to-bronchial anastomosis (CBA) is a rare anomaly. This vascular abnormality may be subclinical or be responsible for several pathophysiological events and symptoms involving the respiratory and/or the coronary system. We report the case of a patient with hemoptysis caused by this anomalous coronary-to-bronchial communication, who was concomitantly affected by aortic stenosis and coronary artery disease requiring surgical treatment. A coronary angiogram clearly demonstrated the abnormal vascular connection between the proximal right coronary artery and the bronchial arteries of the left inferior right lobe. The coronary branch was intra-operatively identified and ligated, in association with aortic valve replacement and coronary artery bypass, with an uneventful postoperative course and resolution of the respiratory symptoms. This case presents an unusual cause of hemoptysis due to CBA in patients with other cardiac comorbidities, which required surgical treatment, allowing direct ligation of the CBA. A review of the clinical and therapeutic characteristics of such a peculiar vascular abnormality is also provided.

The role of plasma biomarkers in acute heart failure. Serial changes and independent prognostic value of NT-proBNP and cardiac troponin-T

AIMS

Brain natriuretic peptide (BNP), NT-proBNP and troponins are useful for the assessment of patients with heart failure. Few data exist about their serial changes and their prognostic value in patients with acute heart failure (AHF).

METHODS AND RESULTS

NT-proBNP and troponin-T plasma levels were measured at baseline, after 6, 12, 24, 48 h and at discharge in 116 consecutive patients with AHF and no evidence of acute coronary syndrome. NT-proBNP levels were 4421 pg/mL at baseline, declined after 24 h and reached their nadir at 48 h (2703 pg/mL). Troponin-T was detectable in 48% of patients. During a median follow-up of 184 days, 52 patients died or had a non-fatal cardiovascular hospitalisation. At a multivariable analysis including clinical and echo-Doppler variables, NT-proBNP plasma levels at discharge, detectable troponin-T plasma levels, and NYHA class at discharge were the only independent prognostic factors.

CONCLUSION

In patients with AHF, NT-proBNP levels decline 24 h after the initiation of intravenous therapy and troponin-T is detectable in 48% of cases. NT-proBNP levels at discharge, detectable troponin-T levels, NYHA class and serum sodium have independent prognostic value.

Cardiac arrest in a patient with a mobile right atrial thrombus in transit and amyloidosis

Primary amyloidosis is a rare disorder in which insoluble fibers are deposited in tissue and organs, impairing their function. Cardiac involvement occurs in up to 50% of patients with primary amyloidosis. We describe a case of a 75-year-old admitted to our department after he had a sudden cardiac arrest due to massive bilateral thrombotic occlusion of the pulmonary arteries. The echocardiogram revealed many atrial thrombi swirling inside the right atrium and protruding into the tricuspid valve partly occluding it. Severe concentric hypertrophy of the left ventricle was also present with a preserved ejection fraction. The right ventricle was dilated, hypertrophic and ipokinetic with a severe tricuspidal insufficiency that permitted estimation of a severe pulmonary hypertension. All these characteristics were highly suggestive for an infiltrative form of hypertrophic cardiomyopathy. The final diagnosis was amyloidosis.

[Interactions between Tax of HTLV1 and cellular factors]

HTLV-1 is a human retrovirus responsible for adult T-cell leukemialymphoma, a monoclonal proliferation of CD4 + T lymphocytes. In addition to the genes encoding the structural proteins and enzymes, the HTLV-1 genome encodes non structural proteins that regulate viral expression as well as various cellular machineries.Among them, Tax has rapidly been identified as the protein responsible for HTLV-1 transforming properties. Tax promotes cell proliferation by activating or repressing cellular genes and by disturbing the mechanisms that control cell division, DNA integrity and apoptosis. These multiple functions rely on the ability of Tax to recruit cytoplasmic and nuclear proteins. The mechanisms involved in the targeting of Tax toward these subcellular sites are still incompletely understood. This review describes the recent data concerning the intracellular maturation of Tax and the control of its functions through posttranslational modifications.

Edge-to-edge mitral valve repair for isolated prolapse of the anterior leaflet caused by degenerative disease

OBJECTIVE

The use of new techniques to correct mitral regurgitation due to prolapse of the anterior leaflet has been shown to expand the original surgical armamentarium and to improve postoperative outcome. We retrospectively analysed our experience with isolated prolapse of the anterior mitral leaflet repaired using the edge-to-edge technique.

METHODS

From October 1986 to June 2004, 790 patients underwent mitral valve repair for mitral regurgitation at our institution. Isolated pathology of the anterior mitral leaflet, due to degenerative disease, was the cause of mitral regurgitation in 84 patients and, from 1991, 68 underwent edge-to-edge repair.

RESULTS

There was no intraoperative death and one in-hospital death. Three patients died in the late follow-up period for a cumulative 13-year survival rate of 90 +/- 1.4%. No patient underwent early reoperation. Four patients underwent reoperation during the follow-up for a cumulative 13-year freedom from reoperation of 92.3 +/- 3.2%. At echocardiographic evaluation, mitral valve repair failure was associated with severe mitral regurgitation in four patients. Of the remaining 60 patients, 40 had no residual regurgitation, 18 had trivial residual regurgitation, and two had mild regurgitation. At follow-up, 49 patients are still in New York Heart Association (NYHA) class I, 14 in NYHA class II and only one in NYHA class III.

CONCLUSIONS

Our study demonstrates that the 'edge-to-edge' technique is a reliable procedure to correct prolapsing leaflets. The addition of this technique to the surgical armamentarium has neutralized prolapse of the anterior leaflet as an incremental risk factor for reoperation.