Italian heart journal : official journal of the Italian Federation of Cardiology最新文献

Background: The aim of this study was to assess the impact of gender on procedural and late clinical outcome in a large cohort of consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in a single center.

Methods: The study included a cohort of 542 consecutive diabetic patients (414 men, 128 women), undergoing PCI for stable and unstable angina. Clinical events were assessed every 6 months for a mean follow-up period of 24 months.

Results: Compared to men, women were older and less often smokers. Insulin requirement was present in a substantially higher percentage of women than men (27 vs 18%, p = 0.03). Presentation with stable angina was more frequent in women, whereas silent ischemia was more prevalent in men. Adverse baseline clinical and angiographic characteristics in women (smaller vessels and longer lesion lengths) were associated with a more frequent need for multiple coronary stenting (23 vs 15% women vs men, p < 0.001) and a higher incidence of peripheral complications (3.2 vs 1.2%, p = 0.049). However, there were no statistically significant gender-related differences in major in-hospital events. Long-term clinical outcome was similar with equivalent incidence of death (4.9 vs 5.3%, p = 0.8), nonfatal myocardial infarction (2.4 vs 4.5%, p = 0.1), need for surgical or repeat percutaneous revascularization between women and men.

Conclusions: Diabetic patients show an increased rate of major adverse cardiac events and target vessel revascularization after PCI. In these patients, female gender is associated with higher procedural complexity and peripheral complications; however, long-term clinical outcome of diabetic women is similar to that of men.

Typical atrial flutter is readily abolished by creating a line of block along the isthmus between the tricuspid annulus and the inferior vena cava. However, postablation atrial fibrillation occurs frequently, and its occurrence increases during the follow-up. Preablation atrial fibrillation is the most important risk factor for postablation atrial fibrillation occurrence. Among patients with preablation atrial fibrillation, patients with drug-induced atrial flutter present a lower risk of postablation atrial fibrillation than patients with spontaneous preablation atrial fibrillation. Patients with preablation lone atrial flutter also present a significant risk of atrial fibrillation development as time passes. Hence, they must be advised of the risk of recurrent symptoms and late atrial fibrillation, and closely followed up despite successful transisthmic ablation. Patients with atrial fibrillation after transcatheter isthmus ablation should be offered catheter-based pulmonary vein isolation, particularly if atrial fibrillation occurs despite continuation of antiarrhythmic drug therapy.

Background: In patients with left bundle branch block (LBBB), conventional tests such as electrocardiography and myocardial scintigraphy poorly evaluate coronary artery disease. It has been reported that myocardial contrast echocardiography (MCE) is capable of identifying patients with a postinfarction contractile reserve and myocardial functional recovery, also allowing the early identification of late left ventricular remodeling. The purpose of this study was to evaluate, retrospectively, myocardial perfusion in selected patients with LBBB.

Methods: Thirty patients (mean age 56 +/- 8 years) with LBBB, 15 with normal coronary arteries at angiography and 15 with a previous myocardial infarction and a critical one-vessel residual stenosis at angiography, underwent MCE from June 2000 to May 2001. MCE results were compared with rest thallium-201 myocardial scintigraphy.

Results: Among 15 LBBB patients with normal coronary arteries, MCE demonstrated normal perfusion in 14 patients, whereas 1 subject showed an impairment of septal perfusion. In the same group, rest thallium-201 myocardial scintigraphy showed an impaired septal perfusion in 14 patients, whereas 1 subject had a normal perfusion (MCE specificity 93% vs myocardial scintigraphy specificity 7%). Among 15 LBBB patients with coronary artery disease, MCE correctly identified a contrast defect in 14/15 patients, whereas rest thallium-201 myocardial scintigraphy demonstrated a perfusion defect in 15/15 patients (MCE sensitivity 93% vs scintigraphy sensitivity 100%). The two techniques showed a good agreement as for myocardial perfusion in the anterior wall (86.6% anterobasal; 86.6% mid-anterior; 80% distal anterior), the inferior wall (86.6%), the distal segment of the posterior lateral wall (83.3%), but a low concordance was found as for the basal septum (16.6%) and middistal septum (33.3%).

Conclusions: MCE allows a diagnostic benefit in the detection of microvascular damage in patients with LBBB and unknown coronary artery disease, also in the presence of discordance with rest thallium-201 myocardial scintigraphy.

Background: The fate of aortic ectasia associated with aortic valve disease is usually derived from the natural history of primitive aortic aneurysm. We evaluated the evolution of untreated aortic dilation following aortic valve replacement and analyzed risk factors for expansion.

Methods: Thirty-eight patients undergoing aortic valve replacement, with an aortic diameter 40 to 55 mm, were followed up for a mean of 42 +/- 28 months (median 36 months). Freedom from adverse events, velocity of aortic expansion and correlation between velocity and several potential risk factors were evaluated.

Results: The mean aortic diameter did not change over time (43 +/- 4 vs 44 +/- 12, p = NS). Velocity of aortic expansion correlated significantly with the diameter of the ascending aorta at the time of operation, with faster growth in patients with ascending aorta diameter > 50 mm (p = 0.0004). Patients with aortic regurgitation had a tendency to a faster aortic dilation compared to those with aortic stenosis (p = 0.10). CONCLUSIONS. In patients without other risk factors, prophylactic surgical treatment of the ectasic aorta seems advisable for diameters > 48 mm. For diameters < 43 mm no treatment is probably needed. Other aspects must be considered for appropriate surgical strategy in the interval between 43 and 48 mm. Patients with aortic regurgitation should be closely monitored.

Background: HIV infection is one of the leading causes of acquired heart disease. Because of its high diffusion, systematic echocardiographic monitoring has been proposed to exclude cardiovascular involvement in these patients. The aim of this study was to evaluate an alternative clinical approach by which echocardiographic screening is limited to patients with a clinical suspicion of heart disease.

Methods: We studied 2030 consecutive HIV-infected patients admitted to a tertiary referral hospital (group A). History, physical examination, ECG, and chest X-ray were used to screen HIV-infected patients for cardiovascular involvement. Selected patients were extensively studied, first of all by echocardiography. Cardiovascular and non-cardiovascular deaths were recorded:

Results: Cardiovascular involvement was clinically suspected in 201 patients (9.9%; group B). Among them a higher extracardiac mortality was found in presence of pericardial disease (odds ratio [OR] 4.27, 95% confidence interval [CI] 2.01-9.09), while a higher cardiovascular mortality was recorded for patients with cardiomyopathy or myocarditis (OR 2.72, 95% CI 1.09-6.81), and right ventricular dysfunction and/or pulmonary hypertension (OR 4.67, 95% CI 1.44-15.2). Compared with group A, patients in group B had a significantly increased cardiac death rate (0.114 vs 0.018, p < 0.001). A positive echocardiogram slightly increased this rate (from 0.114 to 0.164, p = NS), whereas a negative echocardiogram significantly decreased the cardiac death rate (0.015 vs 0.164, p = 0.004).

Conclusions: Clinical selection of HIV-infected patients with suspected cardiovascular involvement may help identify patients with higher frequency of cardiovascular involvement. Among these patients, echocardiography may be a useful screening tool in those at high risk for cardiovascular death.

Redo sternotomy is a challenging surgical procedure performed with increasing frequency; catastrophic hemorrhage is a rare but highly lethal complication. We report our experience in treating this complication in 3 cases of 307 reoperations and propose a simple method to control catastrophic hemorrhage during sternal reentry.

The term "cardiorenal syndrome" has been applied to the presence or development of a renal dysfunction in heart failure patients. Renal function that worsens during hospitalization is a major precipitant of decompensation and cause for admissions in heart failure patients and is a more important predictor of adverse outcome than baseline renal function. Despite growing recognition of the frequent presentation of this combined cardiac and renal dysfunction, its underlying pathophysiology has not been well described and its management remains even less well understood.

In this report we present the case of a double aneurysm, which developed 1 week after pericardiocentesis because of cardiac perforation following aortic valvuloplasty in a newborn. The patient underwent successful surgical treatment through normothermic cardiopulmonary bypass with external plication of double aneurysm.

We report the case of a 41-year-old man presenting with a large Kommerell's diverticulum aneurysm in the right-sided aortic arch with retroesophageal component and moderate thoracic aortic dilation. Surgical treatment was performed through left thoracotomy and consisted of aneurysmectomy, closure of the distal aortic arch defect and aorta-left subclavian artery bypass. After 2 years computed tomography showed no modifications in the thoracic aortic morphology and the patency of the graft to the subclavian artery.

Background: Beta-blockers have provided evidence of improving survival in chronic heart failure patients. Specifically, the Cardiac Insufficiency Bisoprolol Study II has shown a significant reduction in mortality and morbidity among patients with moderate to severe chronic heart failure treated with bisoprolol. Our aim was to investigate the economic consequence of bisoprolol therapy in chronic heart failure patients in Italy.

Methods: Data were derived from the Cardiac Insufficiency Bisoprolol Study II trial. We conducted a cost-effectiveness analysis, comparing standard care with bisoprolol vs standard care with placebo in the perspective of the Italian National Health Service. We identified and quantified medical costs: drug costs according to the Italian National Therapeutic Formulary; specialist visits for initiation and up-titration of bisoprolol therapy and hospitalizations were quantified based on the Italian National Health Service tariffs (2005). Effects were measured in terms of mortality and morbidity reduction (number of deaths, life-years gained and frequency of hospitalizations). We considered an observational period of 1.3 years, i.e. the average follow-up recorded in the trial. Discounting was not performed because of the relatively short follow-up of patients. We conducted one- and multiway sensitivity analyses on unit cost and effectiveness. We also conducted a threshold analysis.

Results: The overall cost of care per 1000 patients treated for 1.3 years was estimated in Euro 2,075,548 in the bisoprolol group and in Euro 2,396,265 in the placebo group, resulting in a net saving of Euro 320,718. The number of additional patients alive with bisoprolol was 55 per 1000 patients, the number of lifeyears gained was 36 at 1.3 year.

Conclusions: Bisoprolol therapy is dominant since it is both less costly and more effective than standard care. Results of sensitivity analysis showed that bisoprolol therapy remains dominant even to changes in unit cost of drug and hospitalizations.