A review of therapeutic approaches for post-infarction left ventricular remodeling

Left ventricular remodeling is an adaptive process initially developed in response to acute myocardial infarction (AMI), but it ends up with negative adverse outcomes such as infarcted wall thinning, ventricular dilation, and cardiac dysfunction. A prolonged excessive inflammatory reaction to cardiomyocytes death and necrosis plays the crucial role in the pathophysiological mechanisms. The pharmacological treatment includes nitroglycerine, β-blockers, ACEi/ARBs, SGLT2i, mineralocorticoid receptor antagonists, and some miscellaneous aspects. Stem cells therapy, CD34+ cells transplantation and gene therapy constitute the promissing therapeutic approaches for post AMI cardiac remodeling, thereby enhancing angiogenesis, cardiomyocytes differenciation and left ventricular function on top of inhibiting apoptosis, inflammation, and collagen deposition. All these lead to reduce infarct size, scar formation and myocardial fibrosis.

Coronary artery aneurysm: A review

Coronary artery aneurysm (CAA) is a clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold diameter of the adjacent normal segment. Atherosclerosis is the main cause in adults and Kawasaki disease in children. CAA is a silent progressive disorder incidentally detected by coronary angiography, but it may end with fatal complications such as rupture, compression of adjacent cardiopulmonary structures, thrombus formation and distal embolization. The pathophysiological mechanisms are not well understood. Atherosclerosis, proteolytic imbalance and inflammatory reaction are involved in aneurysmal formation. Data from previously published studies are scarce and controversial, thereby the management of CAA is individualized depending on clinical presentation, CAA characteristics, patient profile and physician experience. Multiple therapeutic approaches including medical treatment, covered stent angioplasty, coil insertion and surgery were described. Herein, we provide an up-to-date systematic review on the pathophysiology, complications and management of CAA.

Coronary artery disease is associated with valvular heart disease, but could it Be a predictive factor?

OBJECTIVE

This study was conducted to evaluate the prevalence of significant coronary artery disease (CAD) in patients with severe valvular heart disease (VHD) and the association between these two cardiac entities. Our research aims to introduce the theory of a possible causal relationship.

METHODS

A retrospective study was conducted on 1308 consecutive patients who underwent surgery for severe VHD in the cardiovascular department of Notre-Dame de Secours University Hospital (NDSUH) between December 2000 and December 2016. According to transthoracic echocardiography, patients were divided into 4 groups: patients with severe aortic stenosis (AS), patients with severe aortic regurgitation (AR), patients with severe mitral stenosis (MS), and patients with severe mitral regurgitation (MR). Preoperative coronary angiographies were reviewed for the presence or the absence of significant CAD (≥50% luminal stenosis). Chi-square test and 2 × 2 tables were used.

RESULTS

Of the 1308 patients with severe VHD, 1002 patients had isolated aortic valve disease, 240 patients had isolated mitral valve disease, and 66 patients had combined aortomitral valve disease. CAD was detected in 27.75% of all patients with severe VHD, in 32% of patients with isolated aortic valve disease, and in 15% of patients with isolated mitral valve disease. Statistical analysis showed a higher prevalence in patients with severe aortic valve stenosis and a significant relationship between CAD and aortic valve disease, mainly severe AS (p < 0.0001).

CONCLUSION

The prevalence of CAD in patients with VHD is 27.75%, and it correlates significantly with aortic valve disease, in particular with severe AS. Future large studies are needed to evaluate the possible causal relationship.

A Case of Isolated Unilateral Right Renal Vein Thrombosis Associated with Bilateral Pulmonary Embolism Treated with Rivaroxaban a Direct-Acting Oral Anticoagulant

Patient: Female, 44

Final Diagnosis: Renal vein thrombosis

Symptoms: Dyspnea

Medication: —

Clinical Procedure: —

Specialty: Cardiology

A Rare Case of Candida Pericarditis Associated with Esophagopericardial Fistula

Patient: Male, 43

Final Diagnosis: Candida albicans pericarditis

Symptoms: Chest pain

Medication: —

Clinical Procedure: —

Specialty: Cardiology

The lebanese society of cardiology: plans and perspectives, navigating against contrary winds and progressing against all odds

Scientific societies in medicine theoretically aim to improve a medical field as a science; however, this role is expanding nowadays to seeking also the improved practice of a certain medical field. In this regard, the current Lebanese Society of Cardiology (2013-2015) has laid many plans and considered many perspectives. These concern mainly, but not exclusively, the increase of public awareness regarding prevention, investment in research, implementation of guidelines, support of continuous medical education, organization of cardiology symposia and congresses, and achievement of national registries regarding main cardiac conditions, as well as the society's main objective of decreasing the burden of cardiovascular diseases in Lebanon. Nonetheless, the implementation of such plans and perspectives is facing contrary winds related to a multifaceted phenomenon: the dominance of private medicine with a subsequent lack of teamwork, the dominance of private media, the social and political unrest in Lebanon, significant discrepancies in the scientific background of cardiologists, and the absence of a standardized national cardiology licensing exam. Importantly, the implementation of such plans and perspectives requires individual commitment, along with the cooperation of the Order of Physicians, the Syndicate of Hospitals in Lebanon (representing private hospitals) and the Ministry of Health. Moreover, industry must be more committed to medical scientific societies; the support of cardiology events organized without the auspices of the Lebanese Society of Cardiology is not encouraged because of the presence of significant conflict of interest.

Perspectives on the value of biomarkers in acute cardiac care and implications for strategic management

Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.

Haemodynamic effects of intravenous quinacainol with and without autonomic nervous system blockade

Normal subjects are able to compensate negative inotropic drug effects by adrenergic stimulation. This may limit the relevance of hemodynamic investigations with new drugs. Therefore, the haemodynamic effects of a new class 1 antiarrhythmic drug, quinacainol, were evaluated in 16 patients with normal left ventricular function 5 and 25 minutes after intravenous administration in 2 settings: 12 patients were untreated, and 4 patients were pretreated with beta-blockers and atropine to block a reflex adrenergic discharge and vagolytic reaction. Cardiac contractility decreased in all patients: in the untreated group, the heart rate increased from 74 +/- 10 beats per minute to 80 +/- 9 and Vmax decreased from 1.56 +/- 0.56 circ/sec to 1.36 +/- 0.45 at 5 minutes and 1.36 +/- 0.61 at 25 minutes; in the pretreated group, the heart rate did not change. Vmax decreased from 1.61 +/- 0.19 circ/sec to 1.33 +/- 0.08 at 5 minutes and to 1.09 +/- 0.13 at 25 minutes. Autonomic nervous system blockade unmasked a significant persistent negative inotropic effect of the drug in this series of patients with normal left ventricular function. This method may be useful for evaluating the haemodynamic effects of antiarrhythmic drugs in preliminary studies before administration to patients with impaired left ventricular function.

[Mitral valvuloplasty during the 4th month of pregnancy. Fetal protection with a lead mantle]

A 27 year old woman who had undergone closed heart surgical commissurotomy 10 years previously, underwent percutaneous mitral valvuloplasty during the fourth month of her pregnancy. Despite significant valvular thickening with calcification, the balloon dilatation led to an increase in valve surface area from 1.1 to 2 cm2 with no complications and with relief of the pulmonary hypertension. Foetal protection against ionising radiation was assured by a lead mantle completely surrounding the patient's abdomen. This protection reduced irradiation of the pelvic region to 0.5 milliSievert which corresponds to 1/100 of the permitted irradiation of pregnant women professionally exposed to ionising radiation.

Coronary blood flow reserve measured by contrast media injection depends on myocardial viability

Coronary blood flow reserve may be affected by several physiological variables besides hydraulic impediment to flow. A hyperaemic response induced by hyperosmolar radiopaque contrast medium was recorded in the left anterior descending and left circumflex arteries with a steerable pulsed Doppler system in four patients with Q wave anterior myocardial infarction chronic scar and non-stenotic coronary arteries. Resting flow velocities were similar in both arteries. The magnitude of the hyperaemic response induced by contrast media in the circumflex artery (mean flow velocity increase from 5.9 +/- 2.5 baseline to 12.2 +/- 0.6 cm s-1 at peak flow, P less than 0.05) was almost twice that induced in the left anterior descending artery (mean flow velocity increase from 6.1 +/- 2.2 baseline to 7.4 +/- 2.6 cm s-1 at peak flow, P = N.S.). The peak flow to baseline flow velocities ratios were 1.22 +/- 0.15 in the left anterior descending artery vs 2.23 +/- 0.75 in the circumflex artery. Thus when a post-myocardial infarction chronic scar is supplied by a non-stenotic coronary artery, the coronary blood flow hyperaemic response to contrast media-induced transient ischaemia is decreased, suggesting that coronary blood flow reserve depends on a myocardial metabolic stimulus which is impaired by ischaemic cell death.

[Hemodynamic effects of quinacainol administered via an intravenous route. Study in patients with normal left ventricular function]

The haemodynamic effects of a new antiarrhythmic drug quinacainol (RP 54272) were evaluated in 12 untreated patients with normal left ventricular function referred for diagnostic cardiac catheterisation. The haemodynamic data were obtained before, 5 and 25 minutes after the injection of the drug (0.21 mg/kg/min during 6 minutes). A slight decrease of cardiac contractility indexes was constantly observed: dp/dtmax decreased (-15%) in all patients (p less than 0.05), with no concomitant change of left ventricular pressure or left ventricular end diastolic volume with respect to control values. Cardiac output and left ventricular ejection fraction did not change significantly. Heart rate increased in all patients from 74.3 +/- 9.8 to 79.9 +/- 8.6 beats per minute after 5 minutes (paired t test p less than 0.05), and was 79.8 +/- 9.0 beats per minute after 25 minutes. Systemic arterial resistance increased in 7 patients due to a reflex adrenergic discharge. The interpretation of the haemodynamic data was difficult in 3 cases due to systemic vasodilatation, which was poorly tolerated in one patient. The contribution of vagolytic reaction and adrenergic reaction to the negative inotropic effects of the drug must be evaluated before giving in to patients with impaired left ventricular function.

[Evolution of the primary successes of percutaneous aortic valvuloplasty]

Between November 1985 and August 1988, we performed 89 percutaneous aortic valvuloplasties. Sixty-two of these were considered a primary success on the basis of two main criteria: stage I or II on discharge and greater than 50 p. 100 increase in aortic valve area. The mean age of these patients was 78.4 +/- 6.1 years. On actuarial analysis, after 5 months 98 p. 100 of the patients with primary success were alive and 89 p. 100 were in stage I or II and had not been operated upon or redilated. At 15 months 79 p. 100 of the patients with primary success were alive, but only 48 p. 100 were in stage I or II and neither operated upon or redilated. Ultrasonic data obtained one and twelve months after dilatation were compared in 8 patients who had kept the full functional benefit of angioplasty for 14.6 +/- 4.3 months (group 1) and 9 patients who had lost this initial benefit (group 2). In group 1 patients the aortic valve area had moderately and non significantly diminished from 0.92 to 0.72 cm2. In group 2 patients the aortic valve area had gone down from 0.89 to 0.63 cm2 (p less than 0.01), indicating restenosis. We conclude that after the 4th post-valvuloplasty month the medium-term success of the procedure undergoes some degradation, and in these patients the echocardiographic signs of stenosis are clear-cut.

Results of percutaneous valvuloplasty for calcific aortic stenosis with different balloon catheters

Percutaneous aortic valvuloplasty is a palliative treatment for patients with calcific aortic stenosis who would be poor candidates for surgical treatment. The results and associated complications of this procedure were analysed in a series of 47 patients in which different types of dilating catheters were used. In 25 patients a single balloon (19 mm) was used (group A), in 13 patients a bifoil balloon (2 x 15mm) (group B), and in the remaining nine patients (group C) a trefoil balloon (3 x 10mm) was used. An increase in aortic valve area was achieved in all patients. The results obtained with the bifoil balloon were better than with the other types of balloon catheter, with an increase in aortic area of + 118% vs. + 74% (monofoil) and + 76% (trefoil) (P less than 0.05). The tolerance of the inflation procedure was also better with this type of balloon, as it allowed for shorter inflation and deflation times. These results show that balloon aortic valvuloplasty, when indicated, is best performed with a bifoil balloon dilating catheter, and undue complications usually do not occur.

[Development of an ultrasonic system for the recanalization of coronary arteries]

We have devised an electro-acoustic system for the production and propagation of ultrasounds. With this system, linear vibrations can be transmitted through guides that are routinely used for coronary dilatation. Experiments performed on anatomical specimens have shown that ultrasounds are effective in destroying atheromatous formations. In addition, we tested this effectiveness with a setting that modelled the use of this system on the coronary vessels in terms of prerequisites: presence of a carrying catheter, aqueous environment, attention to vascular sinuosities and protection of arterial walls. The biological safety of low-frequency ultrasounds was tested in vitro and in animals. In view of these preliminary results, the subsequent development of an electro-acoustic system to be used in man seems to be justified.

Right heart failure due to an inter-atrial shunt after percutaneous mitral balloon dilatation

Percutaneous mitral valve dilatation was performed in a 61-year-old female patient with severe mitral valve stenosis. The valve could be dilated, but a moderate left to right atrial shunt was present after the procedure. Although the mitral valve area had increased from 1 cm2 to 1.7 cm2, the patient presented 1 week later with right heart failure, explained by right heart volume overload resulting from the persistent shunt. Clinical status quickly improved with diuretics. Although this evolution has not been previously reported, it may be expected in older patients with decreased compliance of pulmonary arteries and right heart chambers.

[Course of aortic valve insufficiency in percutaneous aortic valvuloplasty]

The risk of occurrence or aggravation of aortic valve regurgitation after percutaneous aortic valvuloplasty was evaluated by angiography in 50 consecutive patients: 17 men, 33 women, mean age 77.6 years. In all cases angiography was performed with a pigtail catheter, trying to get the catheter in the same position for injections before and after dilatation. Forty-one patients showed no changes from the predilatation situation: aortic regurgitation was absent in 10 cases, minimal in 30 cases and moderate in 1 case. Minute leakage developed in a patient who had no aortic valve regurgitation prior to dilatation. Regurgitation decreased or subsided in 8 patients, i.e.: moderate leakage became minimal in 6 cases and minimal leakage completely disappeared in 2 cases. In the last 8 patients (3 men, 5 women, mean age 76 years) heart rate and transaortic diastolic pressure gradient were identical before and after dilatation, which means that the angiographic reduction of leakage was due to better closure of the valve. Aortic valve dilatation seems to carry a low risk of major aortic regurgitation. In patients who require percutaneous valvuloplasty for tight aortic valve stenosis, the presence of a small or moderate aortic leakage should not preclude the procedure from being performed.

[Reproducibility of myocardial ischemia induced by atrial stimulation]

Reproducibility of myocardial ischemia induced by atrial pacing (P) was investigated in 25 patients (pts) without previous anterior myocardial infarction and showing a positive exercise stress test. The second period of atrial pacing (P2) was exerted 20 minutes after the first (P1). During P2, a reduction in the parameters reflecting myocardial oxygen requirements (maximal left ventricular pressure, dp/dt max, TTI*HR values) was noted, while the signs of ischemia were less pronounced (ST depression decreasing from 2.3 +/- 1 mm to 1.6 +/- 1.0 mm; % of lactate extraction (%L) decreasing from - 6.4 +/- 25.5 to + 8.5 +/- 19.2; p less than 0.5). The 25 pts were divided into 2 groups according to the ejection fraction (EF greater than .55 16 pts Gr.F+; EF less than .55 9 pts Gr.F-). The distribution of coronary lesions was the same for the 2 groups. During P1 GR.F+ registered a negative % L as opposed to Gr.F-. During P2, the difference in the % L between the 2 groups was also significant (2.6 +/- 19.9% F+ vs 18.9 +/- 14.3% F-; p less than .05). Collateral circulation had no effect upon the results, neither for P1 or P2. This study shows that a second period of atrial pacing, 20 minutes after the first, induced lesser ischemia than the first period of atrial pacing. This phenomenon could explain the paradoxical improvement observed in certain patients after a first episode of angina. These results have implications as regards the necessity of double blind studies compared to placebo when using this technique in the evaluation of the effects of anti-ischemic drugs.